CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Continuous Glucose Monitor and Omnipod Coverage for Insulin-Managed Diabetes

Defines authorization criteria, quantity limits, and coverage duration for CGM/Omnipod supplies for Medicaid members who require multiple daily insulin injections.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyContinuous Glucose Monitor and Omnipod Coverage for Insulin-Managed Diabetes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2021

Next Review DateN/A

Key ActionSubmit documentation showing diagnosis of insulin-managed diabetes, ≥4 daily self-tests, and evidence of inadequate control or recurrent hypoglycemia to request 12 months authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization / coverage duration

4+ /dayself-monitoring frequency requirement

15 /30dquantity limit: Omnipod Pods

1 /30dquantity limit: Omnipod Starter Kit

Medicaidpopulation

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyContinuous Glucose Monitor and Omnipod Coverage for Insulin-Managed Diabetes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2021

Next Review DateN/A

Key ActionSubmit documentation showing diagnosis of insulin-managed diabetes, ≥4 daily self-tests, and evidence of inadequate control or recurrent hypoglycemia to request 12 months authorization.

SourceLink

On This Page

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Initial authorization criteria

Covered when ALL of the following are met

Overall approval conditions

A: The patient has diabetes requiring insulin management with multiple daily injections.
B: The patient is self-testing glucose levels 4 or more times per day.>= 4 tests per day
C
- Inadequate glycemic control.
- Recurrent hypoglycemia.
- Wide fluctuations in blood glucose.
- Dawn phenomenon with early morning excursions.

ref

title": "Initial authorization criteria

This policy applies only to members in the Medicaid population of Neighborhood Health Plan of Rhode Island. Coverage, authorization duration, and quantity limits described in this document are limited in scope to Medicaid members as stated in the policy.

Provider Actions & Authorization Details

Prior Authorization

12-month authorization

An authorization of 12 months may be granted when all clinical criteria are met.

Coverage duration: 12 months

Step Therapy

Step therapy

No explicit step therapy requirements are stated in the source policy. There are no prerequisite medications or trials required prior to approval documented.

Denial Risk

Required clinical documentation / Denial triggers

Denial may occur if the required clinical documentation is not provided. Clinical documentation must demonstrate: (1) diagnosis of diabetes requiring insulin with multiple daily injections; (2) patient self-testing glucose levels 4 or more times per day; and (3) evidence of inadequate glycemic control, recurrent hypoglycemia, wide glucose fluctuations, or dawn phenomenon with early morning excursions with the current diabetes regimen.

Background

Continuous glucose monitoring (CGM) and insulin pump therapy (Omnipod) are intended for patients with diabetes who require intensive insulin management and have difficulty achieving stable glycemic control with current regimens. Indications include recurrent hypoglycemia, wide glucose variability, inadequate glycemic control, or dawn phenomenon with early morning excursions. Authorization is contingent on documentation that the patient requires multiple daily insulin injections and meets the specified monitoring and clinical criteria.

OpenPayer

Continuous Glucose Monitor and Omnipod Coverage for Insulin-Managed Diabetes

Coverage Criteria

Coding and Testing Frequency

Provider Actions & Authorization Details

Background

Definitions