CurrentMedStar Family Choice MarylandPolicy 1413

External Insulin Pumps

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Coverage criteria, authorization, documentation, continued coverage, exclusions, and benefit routing for external insulin pumps used by Maryland members with Type 1 or Type 2 diabetes.

Policy Summary

PayerMedStar Family Choice Maryland

PolicyExternal Insulin Pumps

Policy CodePolicy 1413

Change TypeMaterial revision

Effective DateJuly 1, 2026

Last ReviewJun 1, 2016

Next Review DateN/A

Key ActionFax external insulin pump authorization requests with supporting documentation to MedStar Family Choice; requests are not accepted by phone.

SourceLink

POLICY UPDATE CHANGES

V-Go insulin pump was removed from the policy because it is not a covered benefit.

Eligibility criteria for external insulin pump coverage were broadened.

Disposable insulin delivery systems were clarified as pharmacy-benefit products rather than DME products.

The policy clarified the information required for external insulin pump review and updated supporting references.

Type 1 or Type 2Diabetes populations addressed

≥3/dayRequired insulin injections

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CurrentMedStar Family Choice MarylandPolicy 1413

External Insulin Pumps

Customize your policy alerts

Sign up for medstarfamilychoicemaryland Policy 1413 alerts

Get alerted when Policy 1413 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage criteria, authorization, documentation, continued coverage, exclusions, and benefit routing for external insulin pumps used by Maryland members with Type 1 or Type 2 diabetes.

Policy Summary

PayerMedStar Family Choice Maryland

PolicyExternal Insulin Pumps

Policy CodePolicy 1413

Change TypeMaterial revision

Effective DateJuly 1, 2026

Last ReviewJun 1, 2016

Next Review DateN/A

Key ActionFax external insulin pump authorization requests with supporting documentation to MedStar Family Choice; requests are not accepted by phone.

SourceLink

POLICY UPDATE CHANGES

V-Go insulin pump was removed from the policy because it is not a covered benefit.

Eligibility criteria for external insulin pump coverage were broadened.

Disposable insulin delivery systems were clarified as pharmacy-benefit products rather than DME products.

The policy clarified the information required for external insulin pump review and updated supporting references.

Type 1 or Type 2Diabetes populations addressed

≥3/dayRequired insulin injections

Glucose-testing documentation period

6 monthsContinued-coverage follow-up

4 yearsTypical pump warranty

PharmacyDisposable-system benefit route

Coverage Criteria

Initial Therapy Criteria

External insulin pump therapy is authorized when all required criteria are met.

Initial external insulin pump criteria

Qualified prescriber: The pump must be ordered and managed by an endocrinologist and/or diabetes specialist.
Education and carbohydrate counting: The member must have completed a diabetes self-management education program within the past year and be able to count carbohydrates.Within the past year
Insulin-use pathway
- Multiple-injection pathway: The member requires at least three insulin injections per day for at least six months before initiation of pump therapy.≥3 injections/day for ≥6 months
- Type 1 diabetes pathway: The member has Type 1 diabetes.
Glucose monitoring
- Blood glucose testing: The member tests blood glucose levels at least three times per day during the 60 days before the request.≥3/day during prior 60 days
- CGM monitoring: The member is monitored by CGM.
Technology-use capability: The member understands insulin pump technology and can act based on interpretation of glucose data.
FDA approval: The insulin pump is FDA approved for the member's condition and age.

Continuation Therapy Criteria

Continued coverage requires ongoing diabetes-specialist follow-up.

Continued coverage: The member receives follow-up care and evaluation by an endocrinologist or practitioner specializing in diabetes at least every six months, or more frequently when specified by the prescribing practitioner.At least every 6 months

Medical Exception Review

Requests that do not specifically meet the stated criteria may be submitted for medical-exception review.

Medical exception review: A request outside the listed criteria may be considered when supporting medical records and relevant literature are submitted for Medical Director review.

This is an exception pathway and not an automatic coverage criterion.

Implantable insulin pumps are not a covered benefit under this policy.

A device under the manufacturer’s warranty, including a replacement insulin pump under warranty, is not a covered benefit and remains the manufacturer’s responsibility. The typical pump warranty referenced by the policy is 4 years.

The insulin pump must be FDA approved for the member’s condition and age. Pumps lacking the applicable FDA approval will not be considered.

The V-Go insulin pump is not a covered benefit and should not be authorized under this policy.

Disposable insulin delivery systems are a pharmacy benefit and are not processed as durable medical equipment (DME). Route these products through the pharmacy benefit rather than DME processing.

Coverage Thresholds and Product Details

Multiple daily injections

Injection frequencyAt least 3 insulin injections per day

Required durationFor at least 6 months before insulin pump initiation

Type 1 diabetes exceptionThe multiple-injection requirement does not apply when the member has Type 1 diabetes

Glucose monitoring

Blood glucose testingAt least 3 times per day

Look-back periodDuring the 60 days before the insulin pump request

CGM alternativeMonitoring by continuous glucose monitoring (CGM) may be used instead of documented blood glucose testing

Prior Authorization and Submission Requirements

Prior Authorization

Faxed Prior Authorization Required

The insulin pump company must fax the prior authorization request with supporting documentation to MedStar Family Choice. Authorization requests for insulin pumps are not accepted by phone.

Fax the request and all supporting documentation to MedStar Family Choice.
Do not submit insulin pump authorization requests by phone.

Documentation Required

Include Request and Supply Details

The pre-authorization request or prescription must identify the requested pump and supplies, including the diagnosis, pump type, and applicable HCPCS information.

Diagnosis code
Type of insulin pump
HCPCS codes, descriptions, and quantities for the insulin pump and supplies

External Insulin Pump Therapy

This policy addresses external insulin pump therapy for members with Type 1 or Type 2 diabetes. External pumps provide subcutaneous insulin delivery and may include sensor-augmented or automated insulin delivery features. Appropriate therapy requires patient selection, diabetes-management knowledge, carbohydrate counting, frequent glucose monitoring or CGM use, and the ability to troubleshoot pump or infusion-set problems.

Terminology

Continuous subcutaneous insulin infusion

AbbreviationCSII

DefinitionContinuous subcutaneous insulin infusion

Delivery methodInsulin delivered subcutaneously by an external insulin pump

Continuous glucose monitoring

AbbreviationCGM

DefinitionContinuous glucose monitoring

Policy relevanceCGM monitoring may be used instead of documented finger-stick blood glucose testing for the applicable criterion

Policy Summary

PayerMedStar Family Choice Maryland

PolicyExternal Insulin Pumps

Policy CodePolicy 1413

Change TypeMaterial revision

Effective DateJuly 1, 2026

Last ReviewJun 1, 2016

Next Review DateN/A

Key ActionFax external insulin pump authorization requests with supporting documentation to MedStar Family Choice; requests are not accepted by phone.

SourceLink

On This Page

Continued specialist follow-up

Required follow-upAt least every 6 months

Follow-up providerAn endocrinologist or practitioner specializing in diabetes

More frequent visitsRequired when specified by the prescribing practitioner

Typical pump warranty

Typical warranty period4 years

Warranty replacementReplacement insulin pumps under warranty are not a covered benefit

Financial responsibilityDevices under warranty are the liability of the manufacturer

Disposable pod duration

Maximum durationUp to 3 days

Equivalent duration72 hours

Applies toDisposable patch pump pod

Documentation Required

Certificate of Medical Necessity Required

Submit a Certificate of Medical Necessity signed by the prescribing provider. The signer must be an endocrinologist or a physician or nurse practitioner specializing in diabetes.

Include blood glucose self-testing frequency, blood glucose range, and recent hemoglobin A1C.
Include recommended frequency for changing infusion sets or pods.
Include the diagnosis code and diabetes complications.

Documentation Required

Submit Recent Clinical Notes

Provide office visit notes from the prescribing provider's two most recent encounters. The notes must support the information documented in the Certificate of Medical Necessity.

Submit the last two encounters with the prescribing provider.
Ensure the notes support the CMN and medical-necessity information.

Documentation Required

Provide Glucose Monitoring Records

Document blood glucose self-testing at least three times per day during the 60 days before the pump request, or document that the member is monitored by CGM. A glucose log downloaded by the prescribing provider from the member's meter is preferred.

At least 3 blood glucose tests per day for the preceding 60 days, or CGM monitoring
Prescribing-provider-downloaded blood glucose meter log preferred

Documentation Required

Document Diabetes Education

Submit documentation of recent diabetes self-management education. The member must have completed a diabetes self-management education program within the past year and be able to count carbohydrates.

Include recent diabetes education documentation.
Education must be within the past year.

Denial Risk

Implantable Pumps Excluded

Implantable insulin pumps are not a covered benefit and should be treated as a provider-facing denial risk when requested.

Implantable insulin pumps are excluded from coverage.

Denial Risk

Warranty Replacement Excluded

Replacement of an insulin pump under warranty is not a covered benefit. The manufacturer is liable for devices under warranty; a typical pump warranty is four years.

Devices under warranty are not covered.
Warranty replacement is the manufacturer's responsibility, not MedStar Family Choice's.
Typical pump warranty: 4 years.

Denial Risk

FDA Approval Required

The insulin pump must be FDA approved for the member's specific condition and age. Pumps that are not FDA approved for both are not considered for coverage and may be denied.

Verify FDA approval for the member's condition.
Verify FDA approval for the member's age.

Denial Risk

V-Go Not Covered

V-Go insulin pumps are not a covered benefit. Do not request authorization for V-Go as a covered insulin pump product.

V-Go was removed from the policy because it is not covered.

Billing Rule

Route Disposable Systems to Pharmacy Benefit

Disposable insulin delivery systems are processed under the pharmacy benefit, not as durable medical equipment. Route requests for these systems through the pharmacy-benefit pathway.

Disposable insulin delivery systems, including Omnipod, are pharmacy-benefit items.
Do not process disposable insulin delivery systems as DME.

Automated insulin delivery system

Core componentsAn insulin pump, a CGM device, and an algorithm

Automated functionAutomatically adjusts basal insulin delivery in response to CGM readings

Adjustment directionThe algorithm can increase or decrease basal-rate delivery

Hybrid closed-loop mode

Automated modeThe system is placed in auto mode

Insulin adjustmentBasal insulin delivery can increase or decrease based on sensor glucose values

User interactionThe user must still enter carbohydrate intake to calculate prandial boluses and account for physical activity

Disposable patch pump

Device typeA tubeless disposable insulin pump

Skin-attached componentA pod filled with insulin that is attached to the skin

ControllerA handheld device or personal diabetes manager controls the pod