CurrentCareSource GeorgiaPolicy Insulin Infusion Pump-MP-MM-1316

Insulin Infusion Pump

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Clinical policy governing medical necessity, coverage criteria, exclusions, and replacement/repair rules for external insulin infusion pumps and sensor-augmented systems for members covered by CareSource (Marketplace plans listed). Applies to providers seeking authorization or coverage for pumps and related services.

Policy Summary

PayerCareSource Georgia

PolicyInsulin Infusion Pump

Policy CodePolicy Insulin Infusion Pump-MP-MM-1316

Change TypeNo material change

Effective DateMay 1, 2026

Last ReviewFeb 26, 2025

Next Review Date

Key ActionObtain prior authorization demonstrating all listed medical necessity criteria are met and document diabetes education, maintenance program, and glucose testing logs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ALLCoverage logic

>=6moMDI maintenance

≥4/daySelf-testing

>7%HbA1c threshold

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CurrentCareSource GeorgiaPolicy Insulin Infusion Pump-MP-MM-1316

Insulin Infusion Pump

Customize your policy alerts

Sign up for CareSource Georgia Policy Insulin Infusion Pump-MP-MM-1316 alerts

Get alerted when Policy Insulin Infusion Pump-MP-MM-1316 changes without checking for updates manually.

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Policy Summary

PayerCareSource Georgia

PolicyInsulin Infusion Pump

Policy CodePolicy Insulin Infusion Pump-MP-MM-1316

Change TypeNo material change

Effective DateMay 1, 2026

Last ReviewFeb 26, 2025

Next Review Date

Key ActionObtain prior authorization demonstrating all listed medical necessity criteria are met and document diabetes education, maintenance program, and glucose testing logs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ALLCoverage logic

>=6moMDI maintenance

≥4/daySelf-testing

>7%HbA1c threshold

Coverage Criteria for External Insulin Infusion Pumps

Initial therapy (External insulin infusion pumps)

Covered when ALL of the following are met:

Primary requirements: Member must have a documented diagnosis of T1D or insulin-dependent T2D; diabetic education, equipment, and supplies ordered in writing by a physician or appropriately credentialed provider; provider team experienced in pump management; completion of comprehensive diabetes education within the last 12 months by a certified/registered/licensed provider with diabetes expertise; member or caregiver knowledgeable in operating the device; member participated in a maintenance program for ≥6 months involving ≥3 insulin injections per day with frequent self-adjustments; member performed glucose self-testing an average of ≥4 times per day during the last month; member is at high risk for preventable complications (eg, moderately increased albuminuria) or has persistent difficulty controlling blood glucose despite compliance with an intensive multiple-injection regimen as documented in member logssee child nodes

From Policy D.I through D.I.II

At least one qualifying symptom/condition: Member has at least one of: HbA1C > 7%; history of recurring hypoglycemia; wide preprandial glucose fluctuations; dawn phenomenon frequently exceeding 200 mg/dL; history of severe glycemic excursions (eg, hypoglycemic unawareness, nocturnal hypoglycemia, extreme insulin sensitivity); history or recurrent DKA or hypoglycemia resulting in recurrent and/or prolonged hospitalizationn=1

From Policy D.I.I

Device repair or replacement

Repair or replacement may be covered when ALL of the following are met:

Repair/Replacement conditions: The item is a covered service; continued use of the equipment, supply, or appliance is medically necessary; there is reasonable justification for repair, adjustment, or replacement (eg, worn out, no longer functions, repair impossible or as costly as replacement, member needs changed such as growth); replacement solely because the warranty expired is not considered medically necessarysee text

From Device Replacement or Repair section

CareSource considers certain device types to be not medically necessary and therefore excluded from coverage. These include: portable external insulin infusion pumps requested purely for convenience or member preference, surgically implanted infusion devices, and jet pressure devices. Also excluded are devices associated with chronic intermittent intravenous insulin therapy (CIIIT) and pulsatile intravenous therapy (PIVIT).

Replacement or reimbursement for items that are damaged as a result of misuse, malicious breakage, gross neglect, or items that are lost or stolen is not covered under this policy.

Insulin pump therapy is not medically necessary when the member has end-stage complications such as renal failure. Coverage is also inappropriate when neither the member nor any caregiver is able to operate the pump or perform the frequent blood glucose monitoring required for safe pump use. Examples include a member with advanced renal failure or cognitive/physical limitations and no competent caregiver available to manage device programming, troubleshooting, and frequent glucose checks.

Clinical Thresholds and Monitoring Requirements

Glucose self-testing frequency

Required average daily frequencyAt least 4 times per day on average during the last month

Documentation sourceMember glucose logs demonstrating testing frequency over the past month

Related criterionEvidence required as part of maintenance program and prior authorization

Maintenance program duration

Minimum durationAt least 6 months

Injection frequency during maintenance≥3 insulin injections per day

Purpose

Prior Authorization, Documentation, and Denial Risks

Prior Authorization

Obtain prior authorization; document repair/replacement justification

Prior authorization is required and requests must demonstrate that ALL medical necessity criteria for external insulin infusion pumps are met. For repair or replacement requests, provide documentation that the item is a covered service, continued use is medically necessary, and reasonable justification for repair, adjustment, or replacement (for example: item is worn out, no longer functions, repair is impossible or as costly as replacement, or member's needs have changed). Replacements solely because a warranty expired are not considered medically necessary.

Prior authorization must show all listed coverage criteria are satisfied (diagnosis, education, provider experience, training, maintenance program, self-testing frequency, and qualifying symptom/condition).
For repair/replacement include evidence the device is a covered service, continued medical necessity, and specific justification for repair vs replacement.
Replacement solely due to expired warranty is not medically necessary and should not be authorized.

Step Therapy

Document trial of MDI (≥6 months, ≥3 injections/day) before pump

Background

Insulin therapy is the mainstay of treatment for type 1 diabetes and for insulin-dependent type 2 diabetes. Continuous subcutaneous insulin infusion (CSII) delivered by external insulin pumps can reduce variability in insulin absorption and help members who cannot achieve glycemic targets despite an intensive multiple daily injection (MDI) regimen. Sensor-augmented pump systems that integrate continuous glucose monitoring may reduce nocturnal hypoglycemia. Successful pump therapy requires a motivated and knowledgeable member or caregiver plus a provider team experienced in pump management; adequate training and the ability to perform frequent self-monitoring of blood glucose are essential for safe and effective use.

Definitions

Insulin Infusion Pump

DefinitionAn external pump used to deliver insulin subcutaneously or through an intraperitoneal route in a controlled and programmed way

Route(s) of deliverySubcutaneous or intraperitoneal

Intended usePrevent acute metabolic complications of diabetes and obtain normal blood glucose levels

Sensor-Augmented Insulin Pump System

DefinitionAn insulin infusion pump equipped with a continuous glucose monitor (CGM) sensor that uses CGM readings to modify insulin delivery

IntegrationCGM sensor data used to adjust infusion amounts

System type

Policy Summary

PayerCareSource Georgia

PolicyInsulin Infusion Pump

Policy CodePolicy Insulin Infusion Pump-MP-MM-1316

Change TypeNo material change

Effective DateMay 1, 2026

Last ReviewFeb 26, 2025

Next Review Date

Key ActionObtain prior authorization demonstrating all listed medical necessity criteria are met and document diabetes education, maintenance program, and glucose testing logs.

SourceLink

On This Page

Demonstrates prior trial of intensive multiple daily injection (MDI) therapy before pump initiation

HbA1c threshold

HbA1c thresholdGreater than 7%

ContextOne of the qualifying symptoms/conditions required for pump candidacy

DocumentationRecent lab result included in prior authorization or member chart

Dawn phenomenon threshold

Dawn phenomenon thresholdFrequently exceeding 200 mg/dL

Timing relevanceAssociated with early-morning hyperglycemia; supports pump candidacy when frequent and severe

DocumentationCGM or meter logs showing recurrent early-morning readings >200 mg/dL

Before initiating CSII, document that the member has undergone a maintenance program of at least 6 months using multiple daily injections (MDI) with at least 3 injections per day and frequent self-adjustments of insulin dosage; CSII is considered when MDI has been tried and criteria are otherwise met.

Maintenance program duration: at least 6 months with ≥3 injections/day involving frequent insulin dose adjustments.
Provider must consider and explain the transition from MDI to pump therapy in the member's records.

Documentation Required

Submit full medical necessity documentation (diagnosis, education, MDI program, testing logs)

Include documentation of the member's diagnosis (T1D or insulin-dependent T2D), written orders for diabetic education/equipment by a physician or credentialed provider, completion of comprehensive diabetes education within the last 12 months by certified/registered/licensed personnel, evidence of a ≥6-month maintenance MDI program with ≥3 injections/day, and self-monitoring logs showing an average of ≥4 glucose checks/day during the last month.

Document diagnosis: T1D or insulin-dependent T2D.
Provide written orders for diabetic education, equipment, and supplies from an appropriate provider.
Confirm completion of comprehensive diabetes education within 12 months by certified/registered/licensed provider with diabetes expertise.
Supply logs showing glucose self-testing ≥4 times per day on average in the past month.
Document the maintenance program: ≥6 months with ≥3 injections/day and frequent self-adjustments.

Documentation Required

Attach provider experience, patient/caregiver competency, and objective clinical evidence

Provide supporting clinical documentation of the provider team's expert experience with insulin pumps, evidence the member or caregiver is knowledgeable in operating the device, and objective evidence of qualifying symptoms or failure of prior therapy (for example HbA1c >7%, recurrent hypoglycemia, wide glucose fluctuations, frequent dawn phenomenon >200 mg/dL, severe glycemic excursions, or recurrent DKA/hospitalization).

Document provider and team have expert-level experience managing insulin infusion pumps.
Document member or caregiver competency in device operation.
Attach objective evidence of qualifying conditions (e.g., HbA1C >7%, documented recurrent hypoglycemia, wide preprandial glucose fluctuations, dawn phenomenon >200 mg/dL, severe glycemic excursions, or history of recurrent/prolonged hospitalization for DKA/hypoglycemia).

Denial Risk

Denial/exclusion triggers — end-stage disease, inability to operate or monitor, and non-covered device reasons

Be aware coverage may be denied when the member has end-stage complications (such as renal failure) or when neither the member nor any assisting person can operate the pump or perform frequent blood glucose monitoring; pumps requested purely for convenience or replacement for misuse/loss are also excluded.

Denial conditions: end-stage complications (e.g., renal failure).
Denial conditions: no one available who can operate the pump or perform frequent glucose monitoring.
Not medically necessary: portable external pumps requested solely for convenience/preference; surgically implanted pumps; jet pressure devices; devices for CIIIT or PIVIT.
Replacement not covered if due to misuse, malicious breakage, gross neglect, or lost/stolen items.

Sensor-augmented insulin pump system (pump + CGM)

Moderately Increased Albuminuria

DefinitionPersistent urine albumin-to-creatinine ratio values between 30 and 300 mg/g

SynonymPreviously called microalbuminuria

Clinical significanceUsually indicative of diabetic nephropathy unless other renal disease present

Dawn Phenomenon

DefinitionAn observed increase in blood sugar that occurs in the early morning, often between 2am and 8am

Clinical relevanceMay present as frequent early-morning hyperglycemia supporting pump candidacy

DocumentationCGM or glucose logs showing early-morning rises consistent with dawn phenomenon