CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Twiist Starter Kits and Refill Kits — Coverage Criteria

Covers authorization criteria, quantity limits, and coverage duration for Twiist starter and refill kits for Medicaid members with type 1 diabetes managed with insulin; applies to providers seeking coverage for these kits.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTwiist Starter Kits and Refill Kits — Coverage Criteria

Policy CodePolicy N/A

Change TypeAdministrative (no material clinical changes)

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization documenting patient age, diagnosis of type 1 diabetes on multiple daily injections, frequency of self-monitoring (or CGM use), and evidence of inadequate control or specified glycemic problems.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization/coverage duration

1 kit/30 daysquantity limit

>=6 yrsminimum patient age

>=4/dayself-monitoring requirement

Coverage Criteria for Twiist Starter and Refill Kits

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Initial Authorization Criteria

Covered when ALL of the following are met:

Main approval criteria: A. Patient is 6 years of age or older; B. Patient has type 1 diabetes requiring insulin management with multiple daily injections; C. Patient is self-testing glucose levels 4 or more times per day or is using Continuous Glucose Monitoring (CGM); AND D. The patient has experienced any of the following with the current diabetes regimen: 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.age >= 6 years; self-testing >=4/day or CGM; fasting BG frequently >200 mg/dL is one listed threshold

If all conditions met, authorization for 12 months may be granted.

This policy applies to Medicaid members seeking coverage for Twiist Starter Kits and Refill Kits. The scope is limited to Medicaid; no additional program or population exclusions are specified in the policy.

Requests that do not meet ALL of the listed approval criteria will be considered not medically necessary. Specifically, authorization requires that the patient be ≥6 years old, have type 1 diabetes managed with multiple daily insulin injections, be self-testing ≥4 times per day or using continuous glucose monitoring (CGM), and have evidence of inadequate glycemic control or one of the specified glycemic problems (recurrent hypoglycemia, wide glucose fluctuations, dawn phenomenon with early morning fasting blood sugars frequently > 200 mg/dL, or severe glycemic excursions).

Authorization, Documentation, and Quantity Limits

Prior Authorization

Authorization duration and quantity

If all approval criteria are met, prior authorization may be granted for a coverage duration of 12 months. Quantity is limited to one kit per 30 days.

Coverage duration: 12 months when all approval criteria are met.
Quantity limit: 1 kit per 30 days.

Step Therapy

Step therapy

The policy does not specify any step therapy requirements for Twiist starter or refill kits.

Documentation Required

Required documentation

Document the patient's age, diagnosis of type 1 diabetes requiring multiple daily insulin injections, frequency of self-monitoring (or use of Continuous Glucose Monitoring), and evidence of inadequate glycemic control or one of the listed glycemic problems.

Patient age (must be ≥ 6 years to meet criteria).
Diagnosis: type 1 diabetes requiring multiple daily injections.
Glucose monitoring: self-testing ≥4 times/day or use of CGM.
Evidence of inadequate control or specified glycemic issues (e.g., recurrent hypoglycemia, wide glucose fluctuations, dawn phenomenon, severe excursions).

Denial Risk

Denial risk for unmet criteria

Requests that do not meet all listed approval criteria will be considered not medically necessary and may be denied.

All approval criteria must be met (age ≥6 years; type 1 diabetes on multiple daily injections; self-testing ≥4 times/day or CGM; and evidence of inadequate control or specified glycemic problems).

Clinical Background

Type 1 diabetes requires ongoing insulin therapy and frequent glucose monitoring to guide dosing and reduce the risk of hypoglycemia and hyperglycemia. The policy recognizes the role of frequent self-monitoring (≥4 tests/day) or use of CGM in informing insulin management and in identifying inadequate control, recurrent hypoglycemia, wide glucose variability, dawn phenomenon, or other severe glycemic excursions.

Definitions and Clinical Terms

Definitions — inadequate glycemic control and related thresholds

Inadequate glycemic controlListed as one of the possible problems with the current diabetes regimen that supports authorization.

Recurrent hypoglycemiaDocumented episodes of recurrent low blood glucose are an acceptable reason for authorization.

Wide fluctuations in blood glucoseMarked variability in glucose readings (wide glucose fluctuations) is specified as a qualifying problem.

Dawn phenomenon (fasting BG frequently >200 mg/dL)Dawn phenomenon defined in criteria as early morning fasting blood sugars frequently exceeding 200 mg/dL.

Severe glycemic excursionsSevere excursions in blood glucose are included among the qualifying problems for authorization.