Freestyle Libre 2 Plus CGM System — Medica
Diabetes
Initial criteria
- For Diabetes: Approve for 1 year if the patient meets ONE of the following (A or B):
- A) Patient is using an insulin regimen; OR
- B) Patient is taking a medication for glycemic control other than insulin AND meets ONE of the following (i or ii):
- i. Initial Therapy: Approve if the patient meets ONE of the following (a or b):
- a) Patient had a level 2 hypoglycemia event in the past 6 months; OR
- b) Patient had a level 3 hypoglycemia event in the past 6 months.
- ii. Patient is currently receiving a continuous glucose monitoring system: Approve if the patient meets ONE of the following (a or b):
- a) Patient had a level 2 hypoglycemia event in the 6 months prior to initial continuous glucose monitoring system prescription; OR
- b) Patient had a level 3 hypoglycemia event in the 6 months prior to initial continuous glucose monitoring system prescription.
- For Diabetes in a Pregnant Patient: Approve for 9 months. This includes type 1 diabetes, type 2 diabetes, or gestational diabetes.
Approval duration
1 year for diabetes; 9 months for diabetes in a pregnant patient