CurrentColorado Rocky Mountain Health PlansPolicy 2026T0347WW

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes – Commercial and Individual Exchange Medical Policyopen_in_new

Commercial and Individual Exchange medical policy defining medical necessity coverage criteria for continuous glucose monitors (short-term, long-term, implantable, noninvasive) and external insulin delivery systems (external insulin pumps, nondisposable/patch/nonprogrammable, implantable) for UnitedHealthcare Commercial and Individual Exchange plans. Includes definitions, applicability, duration of authorizations, and lists of applicable procedure, supply, and diagnosis codes.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyContinuous Glucose Monitoring and Insulin Delivery for Managing Diabetes – Commercial and Individual Exchange Medical Policyopen_in_new

Policy CodePolicy 2026T0347WW

Change TypeTemplate Update (archival of prior versions)

Effective DateJan 1, 2026

Next Review Date

Key ActionLong-term CGM requests require meeting coverage criteria whether via UnitedHealthcare prior authorization process or contracted supplier; initial authorization up to 6 months and reauthorization up to 12 months.

SourceLink

POLICY UPDATE CHANGES

Template Update — Created shared policy version to support application to Oxford plan membership and archived previous policy versions (2025T0347VV and DIABETIC 010.49).

implantable CGMCovered Indications Mentioned

noninvasive CGMNot Medically Necessary

implantable pumpsOnly in Clinical Trial

examplesInsulin pump examples listed

examplesCGM models enumerated

1Eversense 365 510k clearance noted

Coverage Summary

This policy (Policy Number 2026T0347WW, effective January 1, 2026) defines UnitedHealthcare Commercial and Individual Exchange coverage criteria for continuous glucose monitors (short-term/professional, long-term external, and implantable), external insulin delivery systems (external insulin pumps, patch/nonprogrammable devices, and implantable pumps), and related supplies. Coverage for proven and medically necessary CGM and insulin delivery is administered under the Durable Medical Equipment (DME) benefit and is subject to member-specific plan terms and limitations. Member eligibility and specific benefit limits should be verified in the member-specific benefit plan document, which governs in the event of conflict. Prior authorization requirements and authorization durations (initial up to 6 months, reauthorization up to 12 months) apply where noted.

Key thresholds and policy dates

Age for implantable CGM>= 18

Intensive insulin therapy definitionInsulin-treated at least 3 times a day or insulin pump

Hypoglycemia level 2Glucose < 54 mg/dL (3.0 mmol/L)

Hypoglycemia level 3Severe event requiring third-party assistance

Policy effective dateJanuary 1, 2026

Policy last_review

Policy next_review

Medical Necessity Criteria

External continuous subcutaneous insulin infusion pumps (external insulin pumps) are considered based on FDA labeling and InterQual criteria. Rendered below are grouped criteria for medically necessary, unproven/not medically necessary, and related rules.

External Continuous Subcutaneous Insulin Infusion Pumps (Insulin Delivery)

Device is used according to FDA labeled indications, contraindications, warnings, and precautions.
Individual requires intensive insulin therapy (insulin-treated at least 3 times per day) or uses an insulin pump for insulin delivery.
Medical necessity clinical coverage criteria are met; refer to the InterQual CP: Durable Medical Equipment, Continuous Glucose Monitors, Insulin Pumps, and Automated Insulin Delivery Technology.
Examples include diabetes due to other causes requiring intensive insulin therapy (e.g., cystic fibrosis-related diabetes, post-transplantation diabetes, diabetes following pancreatic surgery).

Coding

CPT / HCPCS / Category III / S codes (procedures & device insertion/removal)mixed

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 monitor, patient training, removal of sensor, and printout
95251	Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; analysis, interpretation and report

Durable Medical Equipment / Supplies / HCPCS A & E / S codesmixed

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 CGM, 1 month supply = 1 unit
A4239	Supply allowance for nonadjunctive, nonimplanted CGM, 1 month supply = 1 unit
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 CGM, one unit = 1 day supply
A9277	Transmitter; external, for use with nondurable medical equipment interstitial CGM
A9278	Receiver (monitor); external, for use with nondurable medical equipment interstitial 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 (ICD-10) referencedICD-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
E11.21	Type 2 diabetes mellitus with diabetic nephropathy
E11.22	Type 2 diabetes mellitus with diabetic chronic kidney disease
E11.29	Type 2 diabetes mellitus with other diabetic kidney complication
E11.311	Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.319	Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E11.3211	Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye

1–10 of 104

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FDA product codes and device references (informational)mixed

SBA	Eversense 365 CGM system product code (FDA 510k clearance Sept 16, 2024)
MDS/QCD/QHJ	CGM product codes reference for FDA pma/510k lookup
OZP	Product code for automated insulin delivery systems/hybrid closed-loop pumps (informational link)
LZG/QFG	Product codes for external insulin pumps (informational link)

Provider Actions / Prior Authorization

Prior Authorization

Prior authorization requirement and duration

Long-term CGM requests require meeting coverage criteria whether submitted via the UnitedHealthcare prior authorization process or through a contracted supplier. Initial authorizations are granted for up to 6 months; reauthorizations may be granted for up to 12 months.

Initial authorization: up to 6 months
Reauthorization: up to 12 months
Method: UnitedHealthcare prior authorization or contracted supplier

Documentation Required

Six-month adherence assessment for continued CGM

For continued long-term CGM use (external or implantable), the individual must be assessed by a provider every six months for adherence to the prescribed CGM regimen and treatment plan.

Clinical Evidence Summary and Background

Diabetes includes Type 1, Type 2, gestational diabetes, and specific types due to other causes (e.g., cystic fibrosis–related, post-transplant, pancreatitis, monogenic syndromes). Poorly controlled diabetes increases risk of macrovascular and microvascular complications; improved glycemic control has been shown to slow onset or progression of these complications. Insulin delivery devices include standard external insulin pumps (tubed and tubeless/patch systems like OmniPod) that provide programmable basal and bolus dosing, nonprogrammable transdermal delivery systems (e.g., V-Go) that deliver preset basal and bolus doses, and implantable insulin pumps (currently only available in clinical trial settings). Continuous glucose monitors (CGMs) continuously measure interstitial glucose via a sensor, transmitter, and receiver; they include short-term/professional (clinic-placed, generally 7–14 days), long-term external rtCGM and intermittently scanned CGM (isCGM/flash) for personal use, and implantable sensors (e.g., Eversense family). Most benefit plans cover proven, medically necessary CGM and insulin delivery under the Durable Medical Equipment benefit, though coverage limitations and exclusions (including OTC CGMs and noninvasive CGMs) may apply per the member-specific plan.

Label	Value
Eversense ENHANCE study MARD
8.8% overall MARD; 96.6% and 97.9% confirmed alert detection rates at 70 mg/dL and 180 mg/dL; 90% sensors survived 365 days; no related serious adverse events reported
Eversense registry size
>3,000 users enrolled in PMCF registry (3,023 enrolled; 280 completed 4 sensor cycles); no related SAEs reported
HbA1c change after 180 days of sensor wear
−0.43% ±0.69% (p < 0.0001) after 180 days (Irace et al., prospective observational study of 180-day Eversense)
Eversense nominal MARD in 3-way home-use study
14.8% nominal MARD (Eversense) vs 16.3% (Dexcom G5) and 18.0% (Libre Pro) in 3-way home-use study
Eversense PMCF registry enrollment details
3,023 enrolled; 280 completed 4 cycles; most common AEs: sensor site infection, removal difficulty, adhesive irritation; full intended sensor life achieved by 91% of 90-day sensors and 75% of 180-day sensors
Eversense full intended sensor life achieved
91% for 90-day sensors; 75% for 180-day sensors (PMCF registry)
Meta-analysis (Jancev et al. 2024) — HbA1c effect
Average decrease of 3.43 mmol/mol in HbA1c with CGM vs BGM in adults with type 2 diabetes
Meta-analysis — time in range change
Increase of 6.36% in time in range with CGM vs BGM
Other key evidence — PROMISE / PRECISION / PRECISE / PRECISE II / PRECISE trial
PROMISE: up to 180-day Eversense study (n=181); PRECISION/PRECISE trials and pivotal PRECISE trial support accuracy and longevity; ENHANCE (n=110) supported 365-day system (Bailey et al.)

Definitions (concise):

Adjunctive CGM — requires verification with a blood glucose monitor before making treatment decisions.

Non-Adjunctive CGM — may be used to make treatment decisions without a separate fingerstick confirmation.

Professional (Short-Term) CGM — clinic-placed devices worn generally 7–14 days for diagnostic assessment; data may be blinded or visible and devices are not owned by the user.

Intermittently Scanned (Flash) CGM (isCGM) — sensor/transmitter plus separate reader that requires scanning to view and store glucose values; available with or without alarms.

Medicare Determinations

number	name	type	effective date
L33822
Glucose monitors
LCD

Revision History

01/01/2026template_update

Template Update — Created shared policy version to support application to Oxford plan membership and archived previous policy versions (2025T0347VV and DIABETIC 010.49).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyContinuous Glucose Monitoring and Insulin Delivery for Managing Diabetes – Commercial and Individual Exchange Medical Policyopen_in_new

Policy CodePolicy 2026T0347WW

Change TypeTemplate Update (archival of prior versions)

Effective DateJan 1, 2026

Next Review Date

SourceLink

On This Page

For Omnipod 5, refer to the member specific benefit plan document.

External Insulin Pumps - Unproven / Not Medically Necessary

Implantable insulin pumps are unproven and not medically necessary due to insufficient evidence of efficacy.
Nonprogrammable transdermal insulin delivery systems (e.g., V-Go) are unproven and not medically necessary due to insufficient evidence of efficacy.

Short-Term Continuous Glucose Monitoring (Professional CGM, 3-14 days)

Short-term CGM use by a healthcare provider for diagnostic purposes (generally 3-14 days) is proven and medically necessary for managing individuals with diabetes.
Devices are clinic-owned or provided; data may be blinded or visible and used to assess glycemic patterns and trends.

Long-Term Continuous Glucose Monitoring (Greater Than 14 Days) - Duration

Initial CGM authorization will be for up to six months.
Applies to long-term CGM (>14 days).
Reauthorization will be for up to 12 months.
Reauthorization contingent on meeting continued-use criteria.

Long-Term CGM - Intensive Insulin Therapy (Initial and Continued Use)

When used according to FDA labeled indications, contraindications, warnings, and precautions, initial long-term CGM use is proven and medically necessary in certain circumstances; refer to InterQual CP for detailed clinical coverage criteria.
- Device is used according to FDA labeled indications, contraindications, warnings, and precautions.
- Medical necessity clinical coverage criteria are met; refer to the InterQual CP: Durable Medical Equipment, Continuous Glucose Monitors, Insulin Pumps, and Automated Insulin Delivery Technology.
- Individual is assessed by a provider every six months for adherence to the prescribed CGM regimen and treatment plan.

Long-Term CGM - Non-Intensive Diabetes Therapy (Initial Use)

Initial long-term CGM is medically necessary for individuals on a non-intensive treatment plan (e.g., basal insulin and/or oral medications) who have a 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 plan.
Level 2 = glucose < 54 mg/dL; Level 3 = severe event requiring third-party assistance.

Long-Term CGM - Non-Intensive Diabetes Therapy (Continued Use)

Continued long-term CGM is medically necessary when ALL of the following criteria are met:
- Clinical criteria for initial use were met at initiation of CGM.
- Individual is assessed by a provider every six months for adherence to the prescribed CGM regimen and treatment plan.

Long-Term CGM - Not Medically Necessary (Non-Intensive Therapy)

Long-term CGM is unproven and not medically necessary for individuals on a non-intensive treatment plan for all other indications not specified in the initial-use criteria above.

Noninvasive CGM Devices

The use of a noninvasive CGM device is unproven and not medically necessary due to insufficient evidence of efficacy.

Clinical Evidence Summary / Indications and Limitations

Coverage is determined by member-specific benefit plan documents and applicable laws; medical records documentation may be required to assess whether clinical criteria are met but does not guarantee coverage.
Definitions: Adjunctive CGM requires SMBG confirmation prior to treatment decisions; Non-Adjunctive CGM can be used for treatment decisions without SMBG confirmation; Professional CGM is clinic-placed for short-term diagnostic assessment; Real-Time CGM (rtCGM) provides continuous real-time readings and alerts.
Hypoglycemia definitions: Level 2 = glucose < 54 mg/dL; Level 3 = severe event requiring third-party assistance.
Limitations: Short-term/professional CGM is intended for diagnostic use (3-14 days). Long-term CGM initial authorization up to 6 months, reauthorization up to 12 months. Continued use requires six-month provider assessments for adherence. Noninvasive CGM and certain insulin delivery systems (implantable pumps, nonprogrammable transdermal systems) are considered unproven/not medically necessary.

Provider Action / Billing Notes

Refer to InterQual CP for detailed clinical criteria and to member benefit documents for coverage determination.
Supplies and codes (examples) include A4238/A4239 (CGM supplies), A9276 (sensor), A9277 (transmitter), A9274 (external ambulatory insulin delivery), and CPT 95249/95250/95251 for CGM services. Inclusion of codes in policy does not guarantee coverage.

Instructions for Use

Related policies: Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements; Durable Medical Equipment (DME), Prosthetics, Orthotics (Non-Foot Orthotics), Nutritional Therapy, and Medical Supplies Grid; Medicare Advantage and Community Plan policies as applicable.

Documentation Required

Medical records required for review

Medical records documentation may be required to assess whether the member meets the clinical criteria for CGM coverage. Submission of records does not guarantee coverage, and benefit determinations remain subject to the member-specific plan.

Documentation Required

Reference member specific benefit plan

Verify the member-specific benefit plan document and any applicable federal or state mandates before applying this policy. If there is a conflict between this policy and the member-specific plan, the member-specific plan governs.

Documentation Required

Medicare Advantage determinations

In the absence of a Medicare NCD or LCD, Medicare Advantage Organizations may create coverage determinations using objective evidence-based rationale. This policy may be applied to Medicare Advantage plans in certain instances.

Billing Rule

Over-the-counter CGM procurement

Over-the-counter CGM systems obtained through a local pharmacy are out of scope for mailorder DME and this policy. Do not bill mailorder DME for OTC CGM products.

Real-Time CGM (rtCGM) — sensor, transmitter, and receiver/smartphone providing continuous real-time glucose readings and audible alerts.

Hypoglycemia Level 2 — glucose 54 mg/dL (3.0 mmol/L).

Hypoglycemia Level 3 — severe event requiring third‑party assistance; life‑threatening.