Freestyle Navigator Sensor Kit — Medical Mutual

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)