ModifiedColorado Rocky Mountain Health PlansPolicy CS024SS.AG

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes

Clinical coverage criteria and coding for continuous glucose monitors (short- and long-term, implantable and noninvasive), external insulin pumps, and related supplies; governs Colorado Rocky Mountain Health Plans members except where state-specific policies apply.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyContinuous Glucose Monitoring and Insulin Delivery for Managing Diabetes

Policy CodePolicy CS024SS.AG

Change TypeMaterial revisions to coverage rationale and applicable codestemplate updates

Effective DateNovember 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with documentation that the member meets the clinical criteria; initial authorization up to 6 months and reauthorization up to 12 months.

SourceLink

POLICY UPDATE CHANGES

Replaced references to 'non -intensive insulin treatment plan' with 'non -intensive treatment plan'.

Removed CPT code 0447T from Applicable Codes.

Removed content/language pertaining to the state of Louisiana.

Updated Clinical Evidence, FDA, and References sections to reflect the most current information.

6m / 12mInitial/Reauth duration

≥18Minimum age (implantable)

≥3x/day insulinIntensive therapy definition

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.

2026-04-01Most recent history

Coverage Criteria for CGM and Insulin Delivery

Long-term CGM — Intensive Insulin Therapy

Covered when ALL of the following are met:

Device FDA use: Device is used according to FDA labeled indications, contraindications, warnings, and precautions

Clinical criteria: Medical necessity clinical coverage criteria are met per InterQual CP: Durable Medical Equipment, Continuous Glucose Monitors, Insulin Pumps, and Automated Insulin Delivery Technology

Refer to InterQual for specifics

Follow-up: Individual is assessed by a provider every six months for adherence to the prescribed CGM regimen and treatment planevery 6 months

Long-term CGM — Non-Intensive Diabetes Therapy (Initial)

Initial long-term CGM is medically necessary when ALL of the following are met:

Treatment type: Individual is on a non-intensive treatment plan (e.g., basal insulin and/or oral medications)

Hypoglycemia history: History of a level 3 hypoglycemic event OR recurrent (more than one) level 2 hypoglycemic events that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment planlevel 3 OR >1 level 2 events

Implantable CGM (e.g., Eversense) — Initial and Continued Use

Covered when ALL of the following are met:

Device FDA use: Device is used according to FDA labeled indications, contraindications, warnings, and precautions

Age >= 18>=18

Indication: Individual requires intensive insulin therapy (insulin-treated at least 3 times a day or insulin pump) OR has history of a level 3 hypoglycemic event or recurrent (>1) level 2 hypoglycemic events that persist despite multiple attempts to adjust therapy

Short-Term CGM (Professional)

Covered when used by a healthcare provider for diagnostic purposes for defined short-term periods:

Duration: Short-term CGM use for diagnostic purposes for 3-14 days3-14 days

Device coverage considerations

Device-specific coverage considerations and clinical evidence summaries

Implantable insulin pumps are only available in clinical trial settings.

Implantable pumps not standard of care

Nonprogrammable transdermal insulin delivery: Evidence is insufficient to demonstrate safety and efficacy of nonprogrammable wearable disposable insulin delivery devices (e.g., V-Go); further well-designed prospective studies with long-term follow-up are needed.

Caution or additional justification may be required

Insulin pumps for specific diabetes types: Insulin pumps may be considered for specific diabetes types (e.g., cystic fibrosis-related diabetes, post-transplantation diabetes, or diabetes following pancreatic surgery) when insulin deficiency requires multiple daily injections, per professional society guidance despite limited evidence.

Consider case-by-case

Implantable glucose sensors (Eversense):

Evidence summary for implantable CGM

Clinical evidence and indications summarized below:

Accuracy and safety evidence for implantable CGM: Multiple cohort studies, prospective multicenter evaluations, PMCF registry data, and small comparative studies report generally acceptable accuracy (reported MARDs in cited studies ranging roughly from ~8.8% to ~15%) and infrequent serious adverse events for implantable Eversense systems; real-world registries report high sensor survival for intended sensor life across cycles but limitations in study designs exist.MARD approx 8.8%–15% in cited studies; 90% 365-day sensor survival reported for Eversense 365

Sources include PROMISE, PRECISION, PRECISE II, ENHANCE, PMCF registry and other cohort studies

CGM in non-intensive diabetes therapy

RCT and systematic review findings for CGM use in non-intensive (noninsulin) type 2 diabetes:

CGM benefits in noninsulin-treated T2D: Systematic reviews and meta-analyses report CGM use compared with blood glucose monitoring is associated with improved glycemic control (reduced HbA1c, increased time in range, reduced time in hyperglycemia) in adults with type 2 diabetes not using insulin; trials are generally small, short-term, and heterogeneous in device type and monitoring regimens.Average HbA1c decrease ~3.43 mmol/mol reported in a meta-analysis

Evidence quality and duration vary; ECRI updated its assessment in 2025 to a favorable recommendation based on recent systematic review evidence

Implantable insulin pumps and nonprogrammable transdermal insulin delivery systems (for example, V-Go) are considered unproven and not medically necessary due to insufficient evidence of safety and efficacy. The policy notes implantable pumps are only available in clinical trial settings and that the literature on nonprogrammable wearable disposable devices is limited by study design, small sample sizes, high attrition, and lack of long-term comparative data. Individual requests for these devices should be supported by robust clinical evidence; absent that, coverage is not recommended.

Implantable insulin pumps are limited to clinical trial use at this time and are not available for routine coverage. Requests for implantable pump therapies should therefore be directed to clinical study pathways rather than standard benefit coverage.

Continuous glucose monitor systems that are sold over the counter (for example, Dexcom Stelo, Abbott Lingo, Abbott Libre Rio) are out of scope for this DME-focused policy. OTC CGMs obtained via retail pharmacy are not supported through mail-order DME pathways and are handled separately from prescription or implantable CGM authorization processes.

Template updates on 04/01/2026 removed content and language that previously referenced the state of Louisiana. The policy text and history reflect this removal.

Long-term CGM is considered unproven and not medically necessary when used for individuals on a non‑intensive treatment plan for indications other than the specific hypoglycemia criteria listed (history of a level 3 event or recurrent level 2 events despite multiple adjustments). Initial and continued coverage for non‑intensive therapy is limited to the hypoglycemia‑related indications described in the criteria.

Nonprogrammable wearable disposable insulin delivery devices lack sufficient high‑quality evidence to establish safety and efficacy. Published studies are limited, frequently retrospective, and subject to attrition and design biases; as a result, these devices may be considered not medically necessary without further well‑designed prospective comparative data.

Noninvasive continuous glucose monitors (devices that do not require subcutaneous or implantable sensors) currently have no FDA‑approved products. Given the lack of approved devices and supporting regulatory evidence, clinical claims for noninvasive CGMs are unsupported and such devices are considered unproven for routine management of diabetes.

Procedural, Device, and Diagnosis Codes

Procedural CPT/Service CodesCPT

0446T	Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training.
0448T	Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation.
95249	Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; patient-provided equipment, sensor placement, hook-up, calibration of monitor, patient training, and printout of recording.
95250	Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; physician or other qualified health care professional (office) provided equipment, sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording.
95251	Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; analysis, interpretation and report.

HCPCS/Other Device CodesHCPCS

A4226	Supplies for maintenance of insulin infusion pump with dosage rate adjustment using therapeutic continuous glucose sensing, per week.
A4238	Supply allowance for adjunctive, nonimplanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service.
A4239	Supply allowance for nonadjunctive, nonimplanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service.
A9274	External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories.
A9276	Sensor; invasive (e.g., subcutaneous), disposable, for use with nondurable medical equipment interstitial continuous glucose monitoring system (CGM), one unit = 1 day supply.
A9277	Transmitter; external, for use with nondurable medical equipment interstitial continuous glucose monitoring system (CGM).
A9278	Receiver (monitor); external, for use with nondurable medical equipment interstitial continuous glucose monitoring system (CGM).
E0784	External ambulatory infusion pump, insulin.
E0787	External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuous glucose sensing.
E2102	Adjunctive, nonimplanted continuous glucose monitor (CGM) or receiver.

1–10 of 17

1/2

Diagnosis Codes (excerpt)ICD-10

E11.00	Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC).
E11.01	Type 2 diabetes mellitus with hyperosmolarity with coma.
E11.10	Type 2 diabetes mellitus with ketoacidosis without coma.
E11.11	Type 2 diabetes mellitus with ketoacidosis with coma.

Applicable ICD-10 Codes (part 1)ICD-10

E11.3299	Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3311	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E11.3312	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E11.3313	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3319	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
E11.3391	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E11.3392	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E11.3393	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3399	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3411	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye

1–10 of 11

1/2

Applicable ICD-10 Codes (continued)ICD-10

E11.3413	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3419	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye
E11.3491	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
E11.3492	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E11.3493	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3499	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3511	Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye
E11.3512	Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye
E11.3513	Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E11.3519	Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye

1–10 of 77

1/8

Insulin delivery product codes (informational)mixed

LZG	FDA website product code for external insulin pumps (reference)
QFG	FDA website product code for external insulin pumps (reference)
OZP	FDA product code for automated insulin delivery/hybrid closed-loop systems (reference)

CGM product codes (informational)mixed

MDS	FDA product code referenced for CGMs
QCD	FDA product code referenced for CGMs
QHJ	FDA product code referenced for CGMs
SBA	FDA product code for Eversense 365 (510k clearance referenced)

Removed Applicable CodesCPT

0447T

CPT code removed

inv-23: Short-term CGM duration — 3-14 days

Short-term CGM duration3-14 days (professional/diagnostic use)

Use caseHealthcare provider–placed short-term CGM for diagnostic assessment of glycemic patterns

Typical wear period noteGenerally used for discrete short-term periods; cited as 3-14 days in the policy

inv-24: Ambulatory CGM minimum monitoring period — minimum of 72 hours

Minimum ambulatory CGM monitoring period

Provider Responsibilities, Prior Authorization, and Billing Notes

Prior Authorization

Prior Authorization Required

Prior authorization is required for device coverage. Coverage criteria must be met whether the request is submitted via the payer prior authorization process or through a contracted supplier.

Initial CGM authorization duration: up to 6 months
Reauthorization duration: up to 12 months
Requests that do not meet required duration, state, or contract terms may be denied

Prior Authorization

Prior Authorization and Repairs/Replacements

Repair and replacement rules are governed by the Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements policy. Prior authorization and coverage for repairs/replacements are subject to that policy’s requirements and any applicable prior authorization process.

Refer to the Durable Medical Equipment policy for repair/replacement coverage details
Repair/replacement requests may require prior authorization and documentation

Background and Scope

Continuous glucose monitoring (CGM) systems continuously measure interstitial glucose and generally consist of a sensor, transmitter, and receiver or compatible smart device. CGMs are used in two common settings: short‑term (professional) CGM for diagnostic assessment when placed by a healthcare provider for defined periods, and long‑term CGM for ongoing glucose management. Long‑term systems include both external sensors and implantable sensors (for example, Eversense 365, indicated for up to one year in adults). Short‑term professional CGM is typically used for 3–14 days to evaluate glycemic patterns. CGMs may be adjunctive (require confirmatory fingerstick for treatment decisions) or nonadjunctive (cleared to replace fingersticks for treatment decisions); device labeling and FDA indications should guide use. Coverage decisions depend on meeting the policy’s clinical criteria, adherence assessment, applicable FDA labeling, and any relevant federal, state, or contractual benefit requirements.

Definitions and Key Terms

inv-45: Adjunctive CGM — definition

DefinitionAdjunctive CGM: A CGM that requires verification with a blood glucose monitor before making treatment decisions

Source guidanceDefinition referenced to CMS and ADA (2025) within the policy definitions section

Clinical implicationAdjunctive systems cannot be used alone for treatment decisions without confirmatory BGM per definition

inv-46: Hypoglycemia levels — Level 2 and Level 3 definitions

Level 2 hypoglycemiaGlucose <54 mg/dL (3.0 mmol/L); associated with increased risk for cognitive dysfunction and mortality

Level 3 hypoglycemiaA severe event with altered mental and/or physical status requiring third-party assistance; life‑threatening and requires emergent treatment

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyContinuous Glucose Monitoring and Insulin Delivery for Managing Diabetes

Policy CodePolicy CS024SS.AG

Change TypeMaterial revisions to coverage rationale and applicable codestemplate updates

Effective DateNovember 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with documentation that the member meets the clinical criteria; initial authorization up to 6 months and reauthorization up to 12 months.

SourceLink

On This Page

A review concluded the Eversense implantable glucose sensor is an acceptable alternative to standard CGMs; comparative studies suggest clinical validity comparable to other CGM devices, though evidence has limitations and uncertainty regarding accuracy across some conditions.

Coverage may depend on assessment of clinical benefit vs alternatives

Minimum of 72 hours for ambulatory CGM reporting and CPT codes 95249/95250/95251

Relevant CPT codes95249, 95250, 95251 reference a minimum of 72 hours of monitoring

ContextApplies to ambulatory CGM services (patient- or office-provided equipment and interpretation) per policy coding section

inv-25: Sensor survival — 90% survival at 365 days reported for Eversense 365

Sensor survival (Eversense 365)90% of sensors survived 365 days (reported in ENHANCE study)

Study contextENHANCE prospective multicenter nonrandomized study supporting FDA submission; 110 participants

Adverse eventsNo serious adverse events related to device or insertion/removal procedures reported in study

inv-26: MARD (ENHANCE) — Overall MARD 8.8% for Eversense 365

Overall MARD (ENHANCE) for Eversense 365Mean absolute relative difference (MARD) = 8.8%

Alert detection ratesConfirmed alert detection rates 96.6% at 70 mg/dL and 97.9% at 180 mg/dL in the ENHANCE study

Calibration regimenStudy used primarily one calibration per week

inv-27: Transmitter wear time — median 83.2% (first cycle)

Transmitter wear time (median)Median transmitter wear time over the first cycle was 83.2%

Population analyzedAnalysis included 945 users with multiple sensor cycles in retrospective Eversense dataset

StabilityCGM metrics and wear time were similar over subsequent sensor cycles

Note

Device-Specific Authorization Note

Device-specific authorization considerations apply. Refer to FDA product information for device indications and clearance type (PMA, 510(k), PMN) when assessing medical necessity and prior authorization. Implantable CGMs, OTC CGMs, and specific models (e.g., Eversense 365, Dexcom models, Abbott FreeStyle models, Medtronic Guardian) may have distinct indications or age limits.

Use FDA device pages (search by product code such as MDS, QCD, QHJ, SBA) for product-specific indications
Eversense 365 (product code SBA) cleared for up to 1 year in adults — check FDA page for details

Note

Prior Authorization Guidance

This policy is informational. UnitedHealthcare may use third-party tools (for example, InterQual® criteria) to assist in administering benefits and determining medical necessity. Check InterQual for stepwise or additional clinical requirements that may apply to prior authorization decisions.

Click here to view the InterQual® criteria.
Policy references InterQual for clinical-detail guidance and stepwise requirements

Prior Authorization

Authorization Duration and State/Contract Exceptions

Benefit coverage is governed by applicable federal, state, or contractual benefit plan terms. Before using this policy, verify federal/state/contract requirements; in the event of conflict, those requirements govern and may create exceptions to standard authorization durations or coverage.

Check federal, state, and contractual benefit plan terms before applying this policy
Omnipod 5 and similar devices may be subject to federal, state, or contractual requirements

Documentation Required

Diagnosis Coding and Medical Record Documentation

Diagnosis coding must be documented with device claims or prior authorization requests. Medical records may be required to verify that the member meets clinical criteria for coverage.

Include applicable ICD-10 diagnosis codes on claims and prior authorization submissions
Medical records documentation may be requested to support clinical criteria

Note

OTC versus Prescription Pathway

Over-the-counter (OTC) CGM systems obtained through retail pharmacy (e.g., Dexcom Stelo, Abbott Lingo, Abbott Libre Rio) are out of scope for this DME-focused policy and are not supported by mail-order DME providers. OTC CGMs follow the pharmacy/prescription or OTC pathway rather than the DME prior authorization pathway.

OTC CGMs are not covered under this DME policy and are obtained through local pharmacies
Distinct billing and access pathways: OTC/pharmacy vs prescription/mail-order DME

ReferencesDefinitions cited to ADA (2025), McCall et al., 2023; Blonde et al., 2022

inv-47: isCGM (intermittently scanned/flash) — definition

DefinitionisCGM (Intermittently scanned/Flash CGM): Sensor/transmitter plus separate reader; measures continuously but requires scanning to visualize values; may have alarms

ComponentsCombined sensor/transmitter with a separate reader used to scan for stored glucose values

User interactionRequires user-initiated scan to view glucose data (available with or without alarms)

inv-48: Real-Time CGM (rtCGM) — definition

DefinitionReal‑Time CGM (rtCGM): System with sensor, transmitter, and receiver/smartphone that displays glucose readings continuously in real time and may provide audible alerts

ComponentsSensor (subcutaneous catheter), transmitter attached to sensor, and handheld receiver and/or smartphone display

FunctionMeasures and displays glucose levels continuously; some systems require periodic calibration

inv-49: Professional CGM — definition

DefinitionProfessional CGM: Clinic‑owned devices placed for a discrete period (generally 7–14 days) for assessment of glycemic patterns; data may be blinded or visible

Use casePlaced by a healthcare professional for diagnostic assessment; differs from personal rtCGM and isCGM which are user‑owned

Typical durationGenerally worn for 7–14 days when used in clinic-based diagnostic evaluations

inv-50: Diabetes categories — type 1, type 2, gestational, other specific types and complications

Type 1 diabetesAutoimmune beta‑cell destruction leading to absolute insulin deficiency; includes LADA

Type 2 diabetesProgressive loss of beta‑cell insulin secretion with insulin resistance; managed with lifestyle, oral agents, and/or insulin

Other categoriesGestational diabetes and specific types due to other causes (monogenic syndromes, exocrine pancreas disease, drug‑induced, post‑transplant); complications may include retinopathy, nephropathy, neuropathy

inv-51: Insulin delivery devices — descriptions of device types (external pumps, patch devices, OmniPod style, etc.)

External insulin pumps (tubing)Standard pumps connect to tubing that ends with infusion set/needle inserted under the skin and can deliver basal and bolus insulin

OmniPod‑style (patch) systemsIntegrated reservoir placed on the skin with wireless controller to manage dosing (OmniPod® style)

Patch/nonprogrammable devicesNewer patch devices (e.g., V‑Go) deliver preset basal and on‑demand boluses transdermally and may lack programmability; implantable pumps exist in clinical trials

inv-52: Continuous glucose monitors (CGM) — components and types

Core componentsCGMs include a sensor, a transmitter, and a receiver (or smartphone app) to record and display interstitial glucose values

Types of CGMShort‑term/professional CGM, real‑time CGM (rtCGM), intermittently scanned CGM (isCGM); sensors may be disposable or implantable

Implantable sensorsImplantable sensors use fluorescence sensing technology and communicate wirelessly with a smart transmitter and mobile app

inv-53: Eversense 365 — implantable CGM cleared for up to one year in adults 18+

Device descriptionEversense 365: Implantable continuous glucose monitor cleared for up to one year of glucose measurement in individuals 18 years and older

Regulatory statusReceived FDA 510(k) clearance on September 16, 2024 (product code SBA)

IndicationIndicated to replace fingerstick blood glucose measurements for diabetes treatment decisions and may be used alone or with connected devices

inv-54: Noninvasive CGM — definition and note that none are FDA-approved

DefinitionNoninvasive CGM: Devices that monitor glucose without subcutaneous or implantable sensors; not FDA‑approved at time of policy

Policy noteThere are no FDA‑approved noninvasive CGMs on the market at this time per the policy

Coverage implicationNoninvasive CGM claims are unsupported by approved‑device evidence in this document