CurrentUnitedHealthcarePolicy CS024ID.B

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for Idaho Only)

Idaho-specific UnitedHealthcare medical policy (CS024ID.B) governing coverage and medical necessity criteria for continuous glucose monitoring (CGM) devices including implantable long-term sensors and insulin delivery devices; references Idaho Medicaid handbook and DME MAC LCD L33822 for state-specific criteria.

Policy Summary

PayerUnitedHealthcare

PolicyContinuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for Idaho Only)

Policy CodePolicy CS024ID.B

Change TypeState routing; criteria removals; clinical updates

Effective DateAug 1, 2025

Next Review Date

Key ActionFollow Idaho Medicaid Provider Handbook Chapter 5.25 and DME MAC LCD L33822 and document medical records to demonstrate device use per FDA labeling and listed clinical criteria.

POLICY UPDATE CHANGES

Added instruction to refer to the Idaho Medicaid Provider Handbook, Suppliers, Chapter 5.25 for medical necessity clinical coverage criteria for insulin infusion pumps.

Added instruction to refer to the DME MAC LCD for Glucose Monitors (L33822) for medical necessity coverage criteria for short-term and long-term CGM.

Removed language indicating coverage criteria must be met for prior authorization or contracted supplier and removed specified authorization durations (initial up to 6 months; reauthorization up to 12 months).

Removed multiple specific clinical coverage criteria and continued-use criteria for long-term CGM, including criteria for nonintensive insulin-treated individuals with hypoglycemia history.

Removed reference to InterQual® CP as the source for medical necessity clinical coverage criteria.

Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.

3Device categories explicitly stated as unproven/not medically necessary

2Implantable CGM coverage pathways (initial, continued)

6Required follow-up interval (months)

ManyDevice models listed (insulin pumps & CGMs)

L33822Referenced LCD for CGM criteria

2025-08-01Last revision date

Coverage Summary

This is the Idaho‑specific UnitedHealthcare coverage policy CS024ID.B for continuous glucose monitoring (CGM) and insulin delivery, effective August 1, 2025. The policy applies to Idaho, including Idaho Medicaid Plus plans, and includes state‑specific routing to external guidance. Coverage stance is mixed: the policy lists implantable CGM (long‑term) pathways with initial and continued use criteria while identifying several device categories as unproven / not medically necessary. Material changes in this revision include added instructions to refer to the Idaho Medicaid Provider Handbook, Suppliers, Chapter 5.25 for insulin pump criteria and to the DME MAC LCD L33822 for short‑ and long‑term CGM criteria, and removal of operational prior authorization/duration language and multiple prior specific clinical coverage rules. High‑level counts from the brief: 3 device categories stated as unproven/not medically necessary, 2 implantable CGM coverage pathways (initial and continued), 1 required follow‑up interval (every 6 months), and many device models listed (insulin pumps & CGMs).

Quick reference — thresholds & monitoring

Age for implantable CGM>= 18 years

Definition of intensive insulin therapyInsulin-treated at least 3 times a day or insulin pump

Hypoglycemia — Level 2Glucose < 54 mg/dL (3.0 mmol/L)

Hypoglycemia — Level 3Severe event requiring third-party assistance

Provider reassessment intervalEvery 6 months

Intermittently scanned CGM scanning frequencyAt least once every 8 hours

Medical-Necessity Criteria

Initial long-term implantable CGM (e.g., Eversense) - MEDICALLY NECESSARY

Initial long-term CGM using an implantable glucose sensor is medically necessary when ALL of the following are met:

ALL of the following

Device is used according to FDA labeled indications, contraindications, warnings, and precautions
See Instructions for Use
Age ≥ 18>= 18 years
One of the following
- Individual requires intensive insulin therapy (insulin-treated at least 3 times a day or insulin pump)insulin-treated >= 3 times/day or insulin pump

Not Medically Necessary / Unproven Devices

Unproven / Not Medically Necessary devices

The following devices are unproven and not medically necessary due to insufficient evidence of efficacy:

ALL of the following

Implantable insulin pumps
Listed as unproven / not medically necessary
Nonprogrammable transdermal insulin delivery systems (e.g., V-Go)
Listed as unproven / not medically necessary
CGM using a noninvasive device
Noninvasive CGM devices are unproven and not medically necessary; no FDA-approved noninvasive CGMs currently

Removed / Previously Included Coverage Criteria (excerpted as removed in this revision)

Provider Actions & Requirements

Documentation Required

Medical records to support medical necessity

Provide medical records that clearly support medical necessity for initial and continued coverage of implantable continuous glucose monitoring (CGM). Documentation should include: medical history, current diabetes treatment regimen, and objective evidence addressing age, insulin therapy status, and hypoglycemia history. Specifically include:

Age documented (must be ≥ 18 for implantable long‑term CGM).
Evidence of intensive insulin therapy: on multiple daily insulin injections (insulin-treated ≥ 3 times per day) or use of an insulin pump, with documentation of dosing schedule.
If hypoglycemia is the indication: documentation of history of level 3 hypoglycemic event(s) or recurrent (>1) level 2 hypoglycemic events despite ≥ 1 attempts to adjust medications and/or modify the diabetes treatment plan (include dates, circumstances, treatment required, and clinical follow-up).
Provider notes showing device will be used according to FDA‑labeled indications, contraindications, warnings, and precautions (include Instructions for Use when available).
For continuation coverage, documentation of ongoing need for intensive insulin therapy or that initial hypoglycemia criteria were met at initiation, plus evidence of clinical benefit or appropriate management changes based on CGM data.

Coding (CPT / HCPCS / ICD-10 / Other)

CPT / HCPCS procedural codes referencedmixed

0446T	Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training
0447T	Removal of implantable interstitial glucose sensor from subcutaneous pocket via incision
0448T	Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation
95249	Ambulatory continuous glucose monitoring via subcutaneous sensor ≥72 hours; patient-provided equipment, sensor placement, hook-up, calibration, patient training, and printout of recording
95250	Ambulatory continuous glucose monitoring via subcutaneous sensor ≥72 hours; office-provided equipment, sensor placement, hook-up, calibration, patient training, removal of sensor, and printout of recording
95251	Ambulatory continuous glucose monitoring analysis, interpretation, and report
A4226	Supplies for maintenance of insulin infusion pump with dosage rate adjustment using therapeutic continuous glucose sensing, per week
A4238	Supply allowance for adjunctive, nonimplanted CGM, 1 month supply = 1 unit
A4239	Supply allowance for nonadjunctive, nonimplanted CGM, 1 month supply = 1 unit
A9274	External ambulatory insulin delivery system, disposable, each

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Diagnosis codes referenced (ICD-10)ICD-10

E11.00	Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E11.01	Type 2 diabetes mellitus with hyperosmolarity with coma
E11.10	Type 2 diabetes mellitus with ketoacidosis without coma
E11.11	Type 2 diabetes mellitus with ketoacidosis with coma
E11.21	Type 2 diabetes mellitus with diabetic nephropathy
E11.22	Type 2 diabetes mellitus with diabetic chronic kidney disease
E11.29	Type 2 diabetes mellitus with other diabetic kidney complication
E11.311	Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.319	Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E11.3211	Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye

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FDA product codes / references (informational)mixed

LZG	FDA product code referenced for external insulin pumps
QFG	FDA product code referenced for external insulin pumps
OZP	FDA product code referenced for automated insulin delivery systems / hybrid closed-loop pumps
MDS	FDA product code referenced for CGMs
P160048	Eversense CGM PMA number (original)

Example Insulin Pump Models (informational device list)mixed

Beta Bionics iLet	Insulin pump model listed
Insulet Omnipod 5	Insulin pump model listed
Insulet Omnipod DASH	Insulin pump model listed
Medtronic MiniMed 630G	Insulin pump model listed
Medtronic MiniMed 770G	Insulin pump model listed
Medtronic MiniMed 780G	Insulin pump model listed
Sooil Dana Diabecare	Insulin pump model listed
Tandem Mobi	Insulin pump model listed
Tandem t:slim X2 with Basal-IQ	Insulin pump model listed
Tandem t:slim X2 with Control-IQ	Insulin pump model listed

Example Continuous Glucose Monitor Models (informational device list)mixed

Abbott FreeStyle Libre 2	CGM model listed
Abbott FreeStyle Libre 3	CGM model listed
Abbott FreeStyle Libre 14-Day	CGM model listed
Ascensia Eversense E3	CGM model listed
Dexcom G6	CGM model listed
Dexcom G7	CGM model listed
Medtronic Guardian Connect	CGM model listed

CMS/DME MAC LCD referencedmixed

L33822

DME MAC LCD for Glucose Monitors (referenced for state-specific coverage criteria)

Background & Evidence Summary

Evidence summary: implantable CGM systems (example Eversense) have a body of prospective trials, registries, and observational data showing moderate accuracy (reported MARDs ~11–15%) and some improvements in glycemic metrics (HbA1c reductions and reduced time in severe hypoglycemia in select studies), but overall the evidence base is variable in quality and clinical utility remains uncertain for many outcomes. Noninvasive CGM devices currently have no FDA‑approved products and are stated as unproven and not medically necessary due to insufficient evidence. Similarly, implantable insulin pumps and nonprogrammable transdermal insulin delivery systems (e.g., V‑Go) are listed as unproven / not medically necessary because of insufficient high‑quality evidence of safety and efficacy.

Label	Value
Eversense clinical trials	Multiple prospective multicenter studies (PROMISE, PRECISION, PRECISE II, PRECISE) and registry/observational data showing moderate accuracy (MARD ~11-15%) and some reductions in HbA1c/time-below-range; evidence quality variable
Hayes assessment	Hayes HTA: low-quality body of evidence; moderate accuracy vs reference, limited data on health outcomes and substantial uncertainty about clinical utility
Intermittently scanned CGM scanning frequency recommendation	Minimum once every 8 hours to avoid gaps in data (ADA guidance, LOE A)
CGM benefit for HbA1c	When used as an adjunct to pre- and post-prandial blood glucose monitoring, CGM can help achieve HbA1c targets in diabetes and pregnancy (LOE B)
Periodic/professional CGM usefulness	Periodic use of real-time or intermittently scanned CGM or use of professional CGM can be helpful where consistent use is not desired or available (LOE C)

Clinical Practice & Device Use Guidance (informational recommendations)

Guideline-derived recommendations on CGM use and monitoring frequency:

ALL of the following

Intermittently scanned CGM devices should be scanned frequently, at a minimum once every 8 hours to avoid gaps in dataat least once every 8 hours
LOE A per ADA

Definitions / Terms

LOE (Level of Evidence) : A = well‑conducted RCTs/meta‑analyses; B = cohort studies; C = poorly controlled/uncontrolled studies; E = expert consensus/clinical experience.

Medicare Determinations / LCDs

Name	Number	Type	Effective Date
Glucose Monitors	L33822	LCD
Glucose monitors	L33822	LCD

Revision History

08/01/2025added (material)Latest

Added instruction to refer to the Idaho Medicaid Provider Handbook, Suppliers, Chapter 5.25 for medical necessity clinical coverage criteria for insulin infusion pumps.

08/01/2025added (material)Latest

Added instruction to refer to the DME MAC LCD for Glucose Monitors (L33822) for medical necessity coverage criteria for short-term and long-term CGM.

08/01/2025removed (material)

Policy Summary

PayerUnitedHealthcare

PolicyContinuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for Idaho Only)

Policy CodePolicy CS024ID.B

Change TypeState routing; criteria removals; clinical updates

Effective DateAug 1, 2025

Next Review Date

Key ActionFollow Idaho Medicaid Provider Handbook Chapter 5.25 and DME MAC LCD L33822 and document medical records to demonstrate device use per FDA labeling and listed clinical criteria.

On This Page

Individual has a history of a level 3 hypoglycemic event or recurrent (more than one) level 2 hypoglycemic events that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment planHypoglycemia Level 2 = Glucose < 54 mg/dL; Level 3 = severe event needing third-party assistance

Continued long-term implantable CGM (e.g., Eversense) - MEDICALLY NECESSARY

Continued long-term CGM using an implantable glucose sensor is medically necessary when ALL of the following are met:

ALL of the following

Individual continues to require intensive insulin therapy (insulin-treated at least 3 times a day or insulin pump) OR clinical criteria for initial use noted above were met at initiation of CGM for Hypoglycemia
Individual is assessed by a provider every six months for adherence to the prescribed CGM regimen and treatment planevery 6 months
Follow-up assessment required for continued coverage

State-specific references for other CGM/insulin pump criteria

For other CGM types and insulin infusion pumps, refer to state or DME MAC guidance:

ALL of the following

Medical necessity clinical coverage criteria for insulin infusion pumps: refer to the Idaho Medicaid Provider Handbook, Suppliers, Chapter 5.25: Insulin Infusion Pumps
State-specific routing
State-specific medical necessity criteria for short-term and long-term CGM: refer to the DME MAC LCD for Glucose Monitors (L33822)
DME MAC LCD reference

The policy history indicates the following criteria/language were removed from the policy:

ALL of the following

Coverage criteria noted below must be met whether the request comes through the UnitedHealthcare prior authorization process or a contracted supplier
Removed language
Duration of approved authorization: Initial CGM authorization will be for up to six months
Removed language
Reauthorization will be for up to 12 months
Removed language
When used according to FDA labeled indications, contraindications, warnings, and precautions, initial long-term CGM use is proven and medically necessary in certain circumstances
Removed substantive clinical coverage language
For continued long-term use, CGM is proven and medically necessary when all of the following criteria are met: - Device is used according to FDA labeled indications, contraindications, warnings, and precautions - Medical necessity clinical coverage criteria are met - Individual is assessed by a provider every six months for adherence to the prescribed CGM regimen and treatment plan
Removed continued-use criteria
Initial long-term CGM is medically necessary for managing individuals with diabetes on a nonintensive insulin treatment plan (e.g., basal insulin and/or oral medications) who have a history of a level 3 hypoglycemic event or recurrent (more than one) level 2 hypoglycemic events that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan
Removed language expanding initial criteria to nonintensive insulin-treated individuals
Continued long-term CGM is medically necessary for managing individuals with diabetes on a nonintensive insulin treatment plan when all of the following criteria are met: - Clinical criteria for initial use noted above were met at initiation of CGM - Individual is assessed by a provider every six months for adherence to the prescribed CGM regimen and treatment plan
Removed language
Long-term CGM is unproven and not medically necessary for managing individuals with diabetes on a nonintensive insulin treatment plan (e.g., basal insulin and/or oral medications) for all other indications
Removed language
Removed reference to the InterQual® CP: Durable Medical Equipment, Continuous Glucose Monitors, Insulin Pumps, and Automated Insulin Delivery Technology for medical necessity clinical coverage criteria
Removed reference

State-Specific Routing / Referral Requirements (added)

Policy history indicates added state-specific instructions to refer to external sources for medical necessity criteria:

ANY of the following

Refer to the Idaho Medicaid Provider Handbook, Suppliers, Chapter 5.25: Insulin Infusion Pumps for medical necessity clinical coverage criteria for insulin infusion pumps
State-specific added instruction
Refer to the DME MAC LCD for Glucose Monitors (L33822) for medical necessity coverage criteria for short-term and long-term CGM
DME MAC LCD reference added

Prior Authorization

Refer to external/local medical necessity guidance

Refer to applicable state and local guidance for medical necessity and prior authorization requirements for insulin pumps and CGM devices. Idaho‑specific references must be followed when applicable.

Idaho Medicaid Provider Handbook, Suppliers, Chapter 5.25: Insulin Infusion Pumps.
DME MAC Local Coverage Determination (LCD) L33822: Glucose Monitors (covers short‑term and long‑term CGM criteria).

Documentation Required

Six‑month adherence assessment for continued coverage

Assess and document adherence to the prescribed implantable CGM regimen and the patient's diabetes treatment plan at least every six months for continued coverage. The assessment should demonstrate the patient is using the device as prescribed and that data are being incorporated into their treatment.

Document date of each 6‑month adherence assessment and the clinician performing the assessment.
Include objective adherence information (e.g., sensor wear/use history, frequency of data uploads or scans where applicable) and any barriers to use.
Document any clinical changes made based on CGM data and plan for ongoing monitoring.

Documentation Required

Device use, patient education, and monitoring

Document patient education, device use instructions, and adherence monitoring for CGM devices. Ensure education and device use expectations are clearly recorded in the medical record.

Recommend scanning or device interaction at a frequency sufficient to capture glucose trends (minimum every 8 hours for intermittently scanned systems to avoid data gaps).
Monitor and document skin reactions or device‑related adverse events; include management and follow‑up.
Record that the patient received education on: device insertion/removal (if applicable), sensor care, alarm and alert settings, interpretation of readings, when to confirm with a blood glucose meter (if adjunctive), and when to seek medical care.
Document ongoing adherence and any troubleshooting/support provided to improve device use.

CGM should be used as close to daily as possible for maximal benefitdaily use recommended

When used as an adjunct to pre- and post-prandial blood glucose monitoring, CGM can help to achieve HbA1c targets in diabetes and pregnancy

LOE B per ADA

Periodic use of real-time or intermittently scanned CGM or use of professional CGM can be helpful where consistent use is not desired or available

LOE C per ADA

Assess and address skin reactions (irritation or allergy) to aid successful device use

LOE E per ADA

Educate CGM users on potential interfering substances and other factors that may affect accuracy

LOE C per ADA

08/01/2025removed (material)Latest

Removed multiple specific clinical coverage criteria and continued-use criteria for long-term CGM, including criteria for nonintensive insulin-treated individuals with hypoglycemia history.

08/01/2025removed (non-material)Latest

Removed reference to the InterQual® CP as the source for medical necessity clinical coverage criteria.

08/01/2025revised (non-material)Latest

Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.