CurrentCignaPolicy N/A

Diabetes - Simplera Sensors Drug Quantity Management Policy - Per Days

Defines drug quantity management for Simplera and Simplera Sync continuous glucose monitoring sensors and a one-time medical necessity exception allowing additional sensors when premature replacement is required; applies to Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyDiabetes - Simplera Sensors Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeNew policy — material change

Effective DateN/A

Next Review Date05/06/2026

Key ActionApprove a one-time override for 5 additional sensors when a patient's sensor required replacement sooner than the expected 6 days.

SourceLink

POLICY UPDATE CHANGES

New policy created to provide overrides for existing quantity limits to approve 5 additional sensors if the patient's sensor required replacement sooner than the expected 6 days.

5max per 30 days (retail)

15max per 90 days (home)

6intended wear (days)

75.2%% lasting full wear

Coverage Criteria and Exceptions

Policy Summary

PayerCigna

PolicyDiabetes - Simplera Sensors Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeNew policy — material change

Effective DateN/A

Next Review Date05/06/2026

Key ActionApprove a one-time override for 5 additional sensors when a patient's sensor required replacement sooner than the expected 6 days.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Exception for premature sensor replacement (one-time override)

Exceptions to quantity limits are covered when ALL of the following are met

Premature replacement exception: If the patient's sensor required replacement sooner than the expected 6 days, approve a one-time override for 5 additional sensors at retail or home delivery.one-time override = 5 additional sensors

Reasons may include premature adhesive failure (peeling off), insertion issues, sensor signal loss, and connectivity issues.

EXCEPTIONS TO THE QUANTITY LIMITS LISTED ABOVE ARE COVERED AS MEDICALLY NECESSARY WHEN THE FOLLOWING CRITERIA ARE MET. ANY OTHER EXCEPTION IS CONSIDERED NOT MEDICALLY NECESSARY.

Exceptions to the stated quantity limits that do not meet the specified criteria are considered not medically necessary and will not be approved.

Coding, Quantity Limits, and Key Parameters

Covered Codesmixed

No codes listed

inv-05: Maximum quantity per 30 days (retail)

Maximum quantity (retail)5 sensors per 30 days

Package size5 sensors per box

Applicability by productApplies to Simplera Sensor and Simplera Sync Sensor

Coverage contextQuantity limit subject to exception criteria for premature replacement

inv-06: Maximum quantity per 90 days (home delivery)

Maximum quantity (home delivery)15 sensors per 90 days

Package size5 sensors per box

Applicability by productApplies to Simplera Sensor and Simplera Sync Sensor

Coverage contextQuantity limit subject to exception criteria for premature replacement

inv-07: Intended wear duration

Intended wear durationUp to 6 days of wear plus a 24-hour grace period

Observed durability (adults)Approximately 75.2% of adult sensors lasted the full 6-day wear period

Pediatric indication (Simplera Sync)Simplera Sync indicated for patients ≥7 years (arm insertion)

Provider Responsibilities, Program Rules, and Denial Triggers

Documentation Required

Required context and approval duration

Coverage determinations require consideration of the applicable benefit plan document, any applicable laws/regulations, relevant collateral source materials (including coverage policies), and the specific facts of the individual situation. Medical directors should exercise clinical judgment and have discretion in individual coverage decisions. Approvals are provided for the duration noted by the Drug Quantity Management program; one-time approvals are provided for 30 days. When billing, providers must use the most appropriate codes as of the date of submission; claims for services not accompanied by covered diagnosis or procedure codes will be denied.

Required context for coverage determinations: Applicable benefit plan document in effect on date of service; applicable laws/regulations; relevant collateral source materials including coverage policies; specific facts of the particular situation.
Approval duration: All approvals follow the duration specified by the Drug Quantity Management program. One-time overrides (e.g., for premature sensor replacement) are provided for 30 days.

Background

The Simplera system is a real-time continuous glucose monitoring (CGM) system indicated for management of diabetes in adults (≥18 years). Each Simplera sensor is a single-patient, single-use CGM sensor intended to be worn for up to 6 days followed by a 24-hour grace period. The policy applies the Drug Quantity Management limits for Simplera and Simplera Sync sensors and defines a medical necessity exception allowing a one-time override for additional sensors when premature replacement is required.

OpenPayer

Diabetes - Simplera Sensors Drug Quantity Management Policy - Per Days

Coverage Criteria and Exceptions

Coding, Quantity Limits, and Key Parameters

Provider Responsibilities, Program Rules, and Denial Triggers

Definitions

Background

Revision History and Policy Changes