CurrentMass General Brigham Health PlanPolicy 030

Medical Necessity Guidelines Insulin Pumps

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This policy governs medical necessity determinations for insulin pumps and related supplies across Mass General Brigham Health Plan lines of business. It describes coverage pathways, clinical information used for review, exclusions, definitions, and applicable Medicare, MassHealth, ACO, One Care/SCO, and commercial criteria.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Necessity Guidelines Insulin Pumps

Policy CodePolicy 030

Change TypeMaterial revision

Effective DateOct 1, 2026

Last ReviewOct 1, 2026

Next Review DateNot scheduled

Key ActionFor commercial and Qualified Health Plan requests, submit medical history, diabetes education, treatment history, glucose logs, pertinent laboratory testing, and the treatment plan.

SourceLink

POLICY UPDATE CHANGES

The October 2026 ad hoc review updated the Mass General Brigham ACO section.

The January 2026 annual update added a variation for One Care and Senior Care Options members.

The January 2026 annual update added a Medicare National Coverage Determination reference for infusion pumps.

The January 2026 annual update removed the reference to artificial pancreas device systems because that medical policy was retired.

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CurrentMass General Brigham Health PlanPolicy 030

Medical Necessity Guidelines Insulin Pumps

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Sign up for Mass General Brigham Health Plan Policy 030 alerts

Get alerted when Policy 030 changes without checking for updates manually.

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Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Necessity Guidelines Insulin Pumps

Policy CodePolicy 030

Change TypeMaterial revision

Effective DateOct 1, 2026

Last ReviewOct 1, 2026

Next Review DateNot scheduled

Key ActionFor commercial and Qualified Health Plan requests, submit medical history, diabetes education, treatment history, glucose logs, pertinent laboratory testing, and the treatment plan.

SourceLink

POLICY UPDATE CHANGES

The October 2026 ad hoc review updated the Mass General Brigham ACO section.

The January 2026 annual update added a variation for One Care and Senior Care Options members.

The January 2026 annual update added a Medicare National Coverage Determination reference for infusion pumps.

The January 2026 annual update removed the reference to artificial pancreas device systems because that medical policy was retired.

4Member coverage pathways

NoPrior authorization required

5Informational insulin pump and supply codes

<7%Typical adult A1C goal

≤70 mg/dLHypoglycemia treatment threshold

Coverage Criteria

Medicare Advantage

Medical necessity is determined using applicable CMS guidance. Prior authorization is not required.

Applicable CMS authority: Apply the relevant CMS National Coverage Determination, Local Coverage Determination, Local Coverage Article, or documentation in the Medicare manuals. If CMS provides no guidance for the requested service, use Mass General Brigham Health Plan medical policies.

Applicable references include NCD 280.14, LCD L33794, and LCA A52507.

Mass General Brigham ACO

For Mass General Brigham ACO members, follow this ordered medical necessity pathway. Prior authorization is not required.

Ordered pathway

First: Use MassHealth guidance for the specific durable medical equipment (DME).
If MassHealth guidance is unavailable: Refer to the Medicare variation for the relevant Local Coverage Determination (LCD).
If no relevant LCD exists: Refer to the Commercial and Qualified Health Plans section for medical necessity information.

One Care and Senior Care Options

For One Care and Senior Care Options members, apply CMS guidance first, followed by MassHealth criteria when Medicare criteria are unavailable or not met. Prior authorization is not required.

One Care/SCO pathway

First: Use CMS National Coverage Determinations, Local Coverage Determinations, Local Coverage Articles, and documentation included in the Medicare manuals as the basis for medical necessity determinations.
When CMS guidance is unavailable or Medicare criteria are not met: Apply MassHealth medical necessity guidelines.

Commercial and Qualified Health Plans

Medical necessity is determined through InterQual® criteria. Prior authorization is not required.

Coverage criteria

The insulin pump is recommended by the member's providers.
The request meets applicable InterQual® criteria.

Clinical information for review

Medical history is provided or documented.
Diabetes education received is provided or documented.
Treatment to date is provided or documented.

Transdermal insulin delivery systems, including devices such as V-Go, are excluded from the Mass General Brigham Health Plan medical benefit plans. Because these devices are self-use, they may be covered under the plan’s pharmacy benefit.

Replacement or repair of an insulin pump is excluded when the pump is lost, stolen, or damaged due to improper care, misuse, or neglect. The plan may require proof of a stolen or damaged pump, such as a police report, pictures, or a corroborating statement.

Replacement or upgrade of an insulin pump is excluded when the member has a functioning model and the newer or upgraded model is not medically necessary.

Devices or device features principally used for convenience, rather than medical necessity, are excluded from coverage.

Devices or device features considered experimental and investigational are excluded from coverage.

A newer or upgraded insulin pump is not medically necessary when the member already has a functioning model.

Devices or device features principally used for convenience, rather than medical necessity, are not medically necessary.

Coding and Clinical Thresholds

Informational insulin pump and supply codesHCPCS

A4230	Infusion set for external insulin pump, non-needle cannula type
A4231	Infusion set for external insulin pump, needle type
A4232	Syringe with needle for external insulin pump, sterile, 3 cc
A9274	External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories
E0784	External ambulatory infusion pump, insulin

Hypoglycemia treatment threshold

Treatment thresholdBlood glucose of 70 mg/dL or less

Recommended treatmentTreat with fast-acting carbohydrates

Clinical basisThreshold recommended by the International Hypoglycemia Study Group

Hypoglycemia severity thresholds

Serious clinically significant hypoglycemiaBlood glucose below 54 mg/dL

Severe hypoglycemiaSevere cognitive impairment requiring assistance from another person for recovery

Relationship to treatment threshold

Provider Documentation and Denial Risks

Documentation Required

Submit clinical support

For commercial and Qualified Health Plan requests, submit clinical information used for medical necessity review. Incomplete support may prevent the plan from evaluating the request.

Medical history
Diabetes education received
Treatment to date
Glucose reading logs
Pertinent laboratory testing
Treatment plan

Documentation Required

Obtain an annual endocrinologist prescription

The treating endocrinologist must sign a prescription for each requested insulin pump or supply at least yearly. Obtain an updated prescription annually for continued requests.

Insulin Pump Background

An external insulin pump is a computerized, battery-powered device with programming capabilities that delivers insulin subcutaneously in a programmed and controlled manner, reducing the need for self-injection. Some pump systems may integrate continuous glucose monitoring to provide information about glucose fluctuations.

Definitions

Continuous Glucose Monitors

Device typeMinimally invasive or noninvasive device

Measurement siteMeasures glucose levels in the interstitial fluid surrounding skin cells, often through a subcutaneously implanted sensor

FunctionProvides continuous information about glucose fluctuations over several days or for long-term use

Glycated hemoglobin

DefinitionA form of hemoglobin also known as HbA1c

FormationGlucose molecules react with hemoglobin during the approximately 120-day life span of a red blood cell

Clinical meaning

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Necessity Guidelines Insulin Pumps

Policy CodePolicy 030

Change TypeMaterial revision

Effective DateOct 1, 2026

Last ReviewOct 1, 2026

Next Review DateNot scheduled

Key ActionFor commercial and Qualified Health Plan requests, submit medical history, diabetes education, treatment history, glucose logs, pertinent laboratory testing, and the treatment plan.

SourceLink

On This Page

Glucose reading logs are provided or documented.

Pertinent laboratory testing is provided or documented.

The treatment plan is provided or documented.

A blood glucose value of 70 mg/dL or less is sufficiently low for treatment with fast-acting carbohydrates

Typical nonpregnant adult A1C goal

PopulationNonpregnant adults

Typical A1C goalLess than or about 7%

PurposeReduce microvascular and neuropathic complications of diabetes and possibly macrovascular disease

Selected adult A1C goal

PopulationSelected individual adults

A1C goalLess than 6.5%

ConditionUse when significant hypoglycemia or other adverse effects of treatment are avoided

Less stringent adult A1C goal

A1C goalLess than 8% may be appropriate

Higher-risk circumstanceHistory of severe hypoglycemia or limited life expectancy

Additional circumstancesAdvanced microvascular or macrovascular complications, extensive comorbid conditions, or longstanding diabetes in which the general goal is difficult to obtain despite education, monitoring, and appropriate medications

Pediatric A1C goal

PopulationChildren

A1C goalLess than 7.5%

Special considerationAccount for the unique risks of hypoglycemia in very young children

Documentation Required

Provide loss or damage evidence when requested

For a pump that was stolen or damaged, the plan may require proof of the stolen or damaged item. Be prepared to provide supporting evidence when requested.

Police report
Pictures
Corroborating statement

Denial Risk

Transdermal delivery systems are excluded

Coverage may be denied for transdermal insulin delivery systems, including devices such as V-Go, under the medical benefit. Because these devices are self-use, they may be covered under the Mass General Brigham Health Plan Pharmacy benefit plan.

Denial Risk

Loss, theft, misuse, or neglect may prevent replacement

Replacement or repair of an insulin pump may be denied when it is lost, stolen, or damaged due to improper care, misuse, or neglect. The plan may require proof of a stolen or damaged item.

Denial Risk

Support replacement or upgrade as medically necessary

Replacement or upgrade may be denied when the member has a functioning model and the newer or upgraded model is not medically necessary. Document medical necessity for the requested replacement or upgrade.

Denial Risk

Convenience features may be denied

Devices or device features principally used for convenience and not medically necessary are excluded. Requests centered on convenience features may be denied.

Denial Risk

Experimental or investigational technology may be denied

Devices or device features considered experimental and investigational are excluded. Requests involving technology with this designation may be denied.

The amount reflects the average level of glucose to which the red blood cell has been exposed during its life cycle

Hypoglycemia

Hypoglycemia treatment thresholdBlood glucose of 70 mg/dL or less; treat with fast-acting carbohydrates

Serious clinically significant hypoglycemiaBlood glucose below 54 mg/dL

Severe hypoglycemiaSevere cognitive impairment requiring assistance from another person for recovery

External insulin pump

DeviceComputerized, battery-powered device with programming capabilities

Delivery routeDelivers insulin subcutaneously

Delivery methodDelivers insulin in a programmed and controlled manner, eliminating the need for self-injection