Dexcom G4 Platinum — Medical Mutual
Type 1 or type 2 diabetes mellitus requiring short-term continuous glucose monitoring
Initial criteria
- Prescriber is a board-certified endocrinologist, internist, or physician specializing in diabetes management AND is capable of ordering and interpreting continuous glucose monitoring results
- Patient has type 1 or type 2 diabetes mellitus
- For long-term continuous glucose monitoring: ALL of the following:
- - Intensive insulin regimen (4 or more daily insulin injections, or use of continuous subcutaneous insulin infusion pump)
- - Patient is educated or scheduled to be educated on use of continuous glucose monitoring
- For short-term continuous glucose monitoring: ALL of the following:
- - Additional information about blood glucose needed, as indicated by ONE or more of the following:
- * Dawn phenomenon, known or suspected
- * Hypoglycemic unawareness
- * Nocturnal hypoglycemia, known or suspected
- * Postprandial hyperglycemia, known or suspected
- * Significant change to diabetes treatment regimen (e.g. initiation of insulin, change from multiple-dose insulin to insulin pump therapy)
- * Unexplained hyperglycemia
- - Monitoring limited to 3 to 14 days
Reauthorization criteria
- Reapprovals will not be given for instances where equipment was maliciously damaged, neglected, used or misused in a fashion not intended by the manufacturer
Approval duration
365 days (long-term); 14 days (short-term, max 2 approvals/year)