CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Omnipod Starter Kits and Pods Coverage Criteria

Covers authorization, quantity limits, and coverage duration for Omnipod starter kits and pods for members requiring insulin management. Applies to providers requesting coverage from Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOmnipod Starter Kits and Pods Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2021

Next Review Date

Key ActionRequest prior authorization for a 12-month period when the patient meets all approval criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration

15/30dpod quantity limit

1/30dstarter kit quantity limit

≥4x/day or CGMglucose monitoring requirement

Coverage Criteria

Initial Authorization Criteria

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOmnipod Starter Kits and Pods Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2021

Next Review Date

Key ActionRequest prior authorization for a 12-month period when the patient meets all approval criteria.

SourceLink

On This Page

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Requests that do not meet the stated approval criteria are implied to be not medically necessary. Examples include patients who are not on multiple daily injections, those with inadequate documentation of glucose monitoring frequency (i.e., not self-testing ≥4 times/day and not using CGM), or those without documented inadequate glycemic control, recurrent hypoglycemia, wide glucose fluctuations, dawn phenomenon with frequent fasting glucose >200 mg/dL, or other severe glycemic excursions.

Provider Actions & Authorization

Prior Authorization

Prior authorization duration — 12 months

Prior authorization may be granted for 12 months when the approval criteria are met; providers should request authorization covering a 12-month period.

Step Therapy

Step therapy status — none specified

No step therapy requirements are specified in this policy.

Documentation Required

Required documentation to support approval

Documentation must demonstrate the patient meets all approval criteria: diagnosis of diabetes requiring insulin management with multiple daily injections; evidence of self-testing ≥4 times/day or use of Continuous Glucose Monitoring (CGM); and documentation of inadequate glycemic control, recurrent hypoglycemia, wide glucose fluctuations, dawn phenomenon with early morning fasting blood sugars frequently >200 mg/dL, or severe glycemic excursions.

Denial Risk

Denial triggers — incomplete criteria

Requests that do not meet ALL approval criteria risk denial.

Lack of documentation of diabetes requiring multiple daily injections
No evidence of self-testing ≥4 times/day or CGM use
Absence of documented inadequate control, recurrent hypoglycemia, wide glucose variability, dawn phenomenon with fasting glucose frequently >200 mg/dL, or severe excursions

Background

Insulin-requiring patients who are managed with multiple daily injections may be candidates for tubeless insulin delivery via Omnipod pods when they meet the policy’s clinical thresholds. Authorization is contingent on active glucose monitoring—either self-testing ≥4 times per day or use of Continuous Glucose Monitoring (CGM)—and evidence of problematic glycemic control such as inadequate control, recurrent hypoglycemia, large glucose variability, dawn phenomenon with early morning fasting blood sugars frequently exceeding 200 mg/dL, or other severe glycemic excursions.

Definitions

diabetes requiring insulin management with multiple daily injections

DefinitionDiabetes requiring insulin management with multiple daily injections

ContextListed as criterion A for approval of Omnipod supplies when requesting a 12-month authorization

Implication for coverageMember must be on a multiple daily injection insulin regimen to meet this approval criterion

self-testing or Continuous Glucose Monitoring (CGM)

DefinitionSelf-testing glucose levels 4 or more times per day OR use of Continuous Glucose Monitoring (CGM)

Threshold>= 4 self-tests per day when not using CGM

Role in criteriaListed as criterion B required for a 12-month authorization of Omnipod supplies