Sec. 5-16.8a. Rules concerning continuous glucose monitor coverage.

279 words·~1 min read·/il/chapter-305/act-5/5-16-8a

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Sec. 5-16.8a. Rules concerning continuous glucose monitor coverage. The Department shall adopt rules to implement the changes made to Section 356z.59 of the Illinois Insurance Code, as applied to the medical assistance program. The rules shall, at a minimum, provide that:

(1)the ordering provider must be a physician licensed under the Medical Practice Act of

1987 or a certified nurse practitioner or physician assistant with a collaborative agreement with the physician; the ordering provider is not required to obtain continuing medical education in order to prescribe a continuous glucose monitor;

(2)continuous glucose monitors are not required to have an alarm when glucose levels

are outside the predetermined range; the capacity to generate predictive alerts in case of impending hypoglycemia; or the ability to transmit real-time glucose values and alerts to the patient and designated other persons;

(3)the beneficiary is not required to need intensive insulin therapy;

(4)the beneficiary is not required to have a recent history of emergency room visits or

hospitalizations related to hypoglycemia, hyperglycemia, or ketoacidosis;

(5)if the beneficiary has gestational diabetes, the beneficiary is not required to have

suboptimal glycemic control that is likely to harm the beneficiary or the fetus;

(6)if a beneficiary has diabetes mellitus and the beneficiary does not meet the

coverage requirements or if the beneficiary is in a population in which continuous glucose monitor usage has not been well-studied, requests shall be reviewed, on a case-by-case basis, for medical necessity and approved if appropriate; and

(7)prior authorization is required for a prescription of a continuous glucose monitor;

once a continuous glucose monitor is prescribed, the prior authorization shall be approved for a 12-month period.