CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Omnipod

Defines medical necessity criteria for approval of Omnipod pods and starter kits for patients with diabetes requiring insulin, sets quantity limits, and specifies coverage duration and review history.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOmnipod

Policy CodePolicy N/A

Change TypeClarified (no material change)

Effective DateFeb 1, 2021

Next Review DateN/A

Key ActionAuthorization may be granted for 12 months when all criteria are met; provider must document diabetes requiring insulin with multiple daily injections, frequency of glucose testing or CGM use, and evidence of one of the listed glycemic problems.

SourceLink

POLICY UPDATE CHANGES

Reviewed in 1/2021, 1/2022, 4/2023, 4/2024 with effective date 2/1/2021 noted for Omnipod Starter Kits and Pods.

12 monthsCoverage Duration

15/30 daysPods Quantity Limit

1/30 daysStarter Kit Limit

>=4Required daily SMBG checks

Coverage Summary

Scope: Defines medical necessity criteria for outpatient coverage of Omnipod insulin pump pods and starter kits for patients with diabetes requiring insulin management. Quantity limits are 15 pods per 30 days and 1 starter kit per 30 days. Coverage stance: Covered with criteria. Authorization period: 12 months.

Overview: This policy applies to outpatient use of Omnipod pods and starter kits for patients who require multiple daily injections and have evidence of inadequate glycemic control or risk of hypoglycemia. Authorization may be granted for 12 months when the specified clinical criteria are met, and quantity limits are applied as noted.

Quick Facts / Thresholds

Coverage Duration12 months

Pods Quantity Limit15 pods per 30 days

Starter Kit Quantity Limit1 kit per 30 days

Required daily SMBG checks>= 4 times per day

Self-testing frequency threshold>= 4 times per day

Early morning fasting blood sugar threshold> 200 mg/dL

Criteria for Approval

An authorization of 12 months may be granted if:

ALL of the following

The patient has diabetes requiring insulin management with multiple daily injections
The patient is self-testing glucose levels 4 or more times per day or is using Continuous Glucose Monitoring (CGM)>= 4 tests per day
ONE of the following
- Inadequate glycemic control
- Recurrent hypoglycemia
- Wide fluctuations in blood glucose
- Dawn phenomenon with early morning fasting blood sugars frequently exceeding 200 mg/dL> 200 mg/dL (early morning fasting)
- Severe glycemic excursions

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Authorization, Documentation, and Billing Rules

Prior Authorization

Authorization required

Authorization may be granted for 12 months when all criteria are met. The provider must document that the patient has diabetes requiring insulin with multiple daily injections, that the patient self-tests glucose levels 4 or more times per day or uses Continuous Glucose Monitoring (CGM), and that the patient has one of the listed glycemic problems (inadequate glycemic control, recurrent hypoglycemia, wide glucose fluctuations, dawn phenomenon with early morning fasting blood sugars frequently exceeding 200 mg/dL, or severe glycemic excursions).

Document diabetes requiring insulin with multiple daily injections
Document frequency of glucose self-testing (≥4 times/day) or CGM use
Document evidence of one listed glycemic problem (e.g., inadequate control, recurrent hypoglycemia, wide fluctuations, early morning fasting >200 mg/dL, or severe excursions)

Documentation Required

Clinical documentation

Document the frequency of self-monitoring of blood glucose (or use of Continuous Glucose Monitoring) and provide clinical evidence that the patient meets one of the specified conditions: inadequate glycemic control, recurrent hypoglycemia, wide fluctuations in blood glucose, dawn phenomenon with early morning fasting blood sugars frequently exceeding 200 mg/dL, or severe glycemic excursions.

Billing Rule

Quantity limits

Quantity limits apply to Omnipod devices per the policy.

Omnipod Pods: 15 pods per 30 days
Omnipod Starter Kits: 1 kit per 30 days

Background

Background/Intent: The policy sets requirements for outpatient use of the Omnipod insulin delivery system (pods and starter kits) for patients who require multiple daily injections and who have evidence of inadequate glycemic control, recurrent hypoglycemia, wide glucose fluctuations, dawn phenomenon with early morning fasting blood sugars frequently exceeding 200 mg/dL, or severe glycemic excursions. When all criteria are met, authorization may be granted for 12 months.

Definitions: CGM — Continuous Glucose Monitoring.

Revision History

1/2021reviewed

Policy reviewed (no specific clinical policy statement changes noted)

1/2022reviewed

Policy reviewed (no specific clinical policy statement changes noted)

4/2023reviewed

Policy reviewed (no specific clinical policy statement changes noted)

4/2024reviewedLatest

Policy reviewed (no specific clinical policy statement changes noted)

2021-02-01effective_date

Effective date for Omnipod Starter Kits and Pods

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOmnipod

Policy CodePolicy N/A

Change TypeClarified (no material change)

Effective DateFeb 1, 2021

Next Review DateN/A

SourceLink

On This Page

OpenPayer

Omnipod

Coverage Summary

Criteria for Approval

Codes and Device Descriptions

Authorization, Documentation, and Billing Rules

Background

Revision History

	Omnipod Pods (e.g., Omnipod 5 Libre2 G6, 5 G7, G7G6, DASH, GO)
	Omnipod Starter Kits