CurrentmedstarfamilychoicedistrictofcolumbiaPolicy 1413.DC

External Insulin Pumps

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Defines medical necessity criteria, documentation, and coverage limits for external (non-implantable) insulin pumps and related supplies for MedStar Family Choice DC enrollees with type 1 or type 2 diabetes.

Policy Summary

Payermedstarfamilychoicedistrictofcolumbia

PolicyExternal Insulin Pumps

Policy CodePolicy 1413.DC

Change TypeBroadened eligibilityclarified coverage and benefit processing for disposable patch pumps

Effective DateOct 1, 2020

Last ReviewJul 25, 2025

Next Review DateN/A

Key ActionSubmit a faxed prior authorization request from the insulin pump company including order/prescription, diagnosis code, pump type, HCPCS codes, and required supporting documentation.

SourceLink

POLICY UPDATE CHANGES

Broadened eligibility for coverage criteria and simplified disposable insulin delivery systems section reflecting coverage through pharmacy benefits.

Updated reference date for American Diabetes Association Standards of Medical Care in Diabetes and updated references.

Clarified that insulin pumps must be FDA-approved for the enrollee's condition and age and that implantable pumps are not covered.

≥3min daily BG tests (60d lookback)

6 monthsMDI duration before pump

every 6 months

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CurrentmedstarfamilychoicedistrictofcolumbiaPolicy 1413.DC

External Insulin Pumps

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Sign up for medstarfamilychoicedistrictofcolumbia Policy 1413.DC alerts

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Policy Summary

Payermedstarfamilychoicedistrictofcolumbia

PolicyExternal Insulin Pumps

Policy CodePolicy 1413.DC

Change TypeBroadened eligibilityclarified coverage and benefit processing for disposable patch pumps

Effective DateOct 1, 2020

Last ReviewJul 25, 2025

Next Review DateN/A

Key ActionSubmit a faxed prior authorization request from the insulin pump company including order/prescription, diagnosis code, pump type, HCPCS codes, and required supporting documentation.

SourceLink

POLICY UPDATE CHANGES

Broadened eligibility for coverage criteria and simplified disposable insulin delivery systems section reflecting coverage through pharmacy benefits.

Updated reference date for American Diabetes Association Standards of Medical Care in Diabetes and updated references.

Clarified that insulin pumps must be FDA-approved for the enrollee's condition and age and that implantable pumps are not covered.

≥3min daily BG tests (60d lookback)

6 monthsMDI duration before pump

every 6 months

Coverage Criteria for External Insulin Pumps

Implantable insulin pumps are not a covered benefit for MedStar Family Choice District of Columbia enrollees.

Devices that remain under the manufacturer's warranty are not a covered benefit and are the liability of the manufacturer; replacement of insulin pumps while under warranty is not a covered benefit. Typical pump warranty period cited in the policy is 4 years.

Disposable insulin delivery systems (for example, Omnipod) are processed as a pharmacy benefit rather than DME; limitations for these systems are described in the disposable insulin delivery systems section.

Only insulin pumps that are FDA‑approved for the enrollee's condition and age will be considered for coverage; pumps that are not FDA‑approved for the enrollee’s condition and age are excluded.

Replacement of an insulin pump that is still covered under the manufacturer's warranty is not covered. Requests for warranty replacements may be denied as not medically necessary.

Coding and Utilization Criteria

Required codes on authorization requestmixed

Diagnosis Code	Diagnosis code required on order/prescription (document references diabetes diagnosis code but does not list specific ICD-10 codes)
HCPCS codes	HCPCS codes, description and quantities for insulin pump and supplies must be included on the request (specific HCPCS not listed)

inv-08: CGM utilization lookback — ≥70% utilization during lookback period

CGM utilization requirementCGM compliance defined as ≥70% utilization during the lookback period

Context in eligibilitySatisfies the glucose-monitoring element of initial coverage when documented during the 60-day lookback

Evidence acceptedCGM usage records demonstrating ≥70% utilization must be included with the authorization request

inv-09: Blood glucose testing frequency — ≥3 tests per day during the 60 days prior to request

Minimum testing frequencyPatient must have tested blood glucose ≥3 times per day during the 60 days prior to the request

Alternate to testingRequirement may be met instead by documented CGM use (≥70% utilization during lookback)

DocumentationBlood glucose logs from the prior 60 days demonstrating ≥3 tests/day should be submitted with the authorization

inv-10: Prior MDI duration — At least 6 months of ≥3 injections per day (unless type 1 diabetes)

Minimum durationPatient must have used multiple daily injections (≥3 injections per day) for at least 6 months prior to pump initiation

ExceptionRequirement does not apply to patients with type 1 diabetes

DocumentationClinical records confirming injection frequency and duration must be provided with the authorization request

Provider Actions and Documentation Requirements

Prior Authorization

Preauthorization required

Prior authorization is required for insulin pumps. The insulin pump company should fax a request for authorization with supporting documentation to MedStar Family Choice; authorization requests for insulin pumps are not taken via phone.

Request must be faxed by the insulin pump company
Phone requests are not accepted

Step Therapy

Prior MDI requirement

Patient must have used multiple daily injections (at least three insulin injections per day) for at least 6 months prior to initiation of an insulin pump unless the patient has type 1 diabetes.

Background and Clinical Context

External insulin pumps (continuous subcutaneous insulin infusion, CSII) deliver insulin continuously via a wearable pump and are used in people with type 1 and type 2 diabetes. Modern systems may be sensor‑augmented or operate as hybrid closed‑loop (automated delivery) devices that integrate CGM data to suspend or adjust basal insulin while still requiring user‑initiated boluses for meals and corrections. Successful pump therapy requires diabetes education, ability to count carbohydrates, frequent glucose monitoring or reliable CGM use, and the ability to troubleshoot pump issues.

Definitions

inv-17: Definition — Hybrid closed-loop (automated delivery) pumps: systems that automatically adjust basal insulin delivery in response to CGM while requiring user-initiated boluses.

Core definitionHybrid closed-loop pumps automatically adjust basal insulin delivery (increase or decrease) in response to CGM sensor glucose values while still requiring user-initiated boluses for meals and corrections

Operational noteThese systems may be used alone or with a CGM and are commonly referred to as 'auto' or hybrid closed-loop when in automated mode

Clinical implicationUsers must still bolus for carbohydrate intake and corrections despite automated basal adjustments

inv-18: Definition — Disposable patch pumps (e.g., Omnipod, V-GO) are tubeless or single-use wearable insulin delivery devices; operational details.

Device descriptionDisposable patch pumps are tubeless wearable insulin delivery devices (examples: Omnipod, V-GO)

Documentation Required

Required documentation for authorization

Order/prescription for preauthorization must include the diagnosis code, type of insulin pump, and HCPCS codes with descriptions and quantities. The Certificate of Medical Necessity (CMN) signed by the prescribing provider must document testing frequency, blood glucose range, recent hemoglobin A1c, infusion set/pod change frequency, diagnosis code, and diabetes complications; include office visit notes from the last two encounters, blood glucose logs showing testing 3 times/day in the prior 60 days (or evidence of CGM use), and documentation of recent diabetes education.

Order/prescription must list: diagnosis code; type of insulin pump; HCPCS codes, descriptions, and quantities
CMN must include testing frequency, glucose range, recent HbA1c, infusion set/pod change frequency, diagnosis code, and diabetes complications
Include office visit notes from last two encounters and blood glucose logs (3×/day in prior 60 days) or CGM documentation
Document recent diabetes education