ModifiedUnitedHealthcarePolicy CS024ID.E

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

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Coverage criteria for continuous glucose monitors and insulin delivery devices used to manage diabetes for UnitedHealthcare Community Plan members in Idaho, including Idaho Medicaid Plus plans.

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ModifiedUnitedHealthcarePolicy CS024ID.E

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

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Coverage criteria for continuous glucose monitors and insulin delivery devices used to manage diabetes for UnitedHealthcare Community Plan members in Idaho, including Idaho Medicaid Plus plans.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS024ID.E

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateNot specified

Key ActionFor Idaho-specific medical necessity criteria, refer to the Idaho Medicaid Provider Handbook for insulin infusion pumps and DME MAC LCD L33822 for short-term and long-term non-implantable CGM.

SourceLink

POLICY UPDATE CHANGES

CPT/HCPCS codes 0446T, 0448T, S1030, S1031, S1034, S1035, S1036, and S1037 are not on the State of Idaho Medicaid Fee Schedule and may not be covered.

The Description of Services, Clinical Evidence, FDA, and References sections were updated.

Idaho onlyPolicy application

18 yearsInitial implantable CGM minimum age

≥3/dayIntensive insulin therapy

<54 mg/dLLevel 2 hypoglycemia

6 monthsContinued CGM reassessment

8Codes not on Idaho fee schedule

Medical Necessity and Coverage Criteria

Initial Long-Term Implantable CGM

Initial long-term CGM using an implantable glucose sensor is medically necessary for managing individuals with diabetes when ALL of the following criteria are met:

ALL of the following

Device is used according to U.S. Food and Drug Administration (FDA)-labeled indications, contraindications, warnings, and precautions.
Individual is age 18 years or older.≥ 18 years
ONE of the following
- Individual requires intensive insulin therapy, defined as insulin treatment at least three times a day or use of an insulin pump.
- 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 plan.

Continued Long-Term Implantable CGM

Continued long-term CGM using an implantable glucose sensor is medically necessary for managing individuals with diabetes when ALL of the following criteria are met:

ALL of the following

ONE of the following
- Individual continues to require intensive insulin therapy, defined as insulin treatment at least three times a day or use of an insulin pump.
- Clinical criteria for initial use noted above were met at initiation of CGM for hypoglycemia.
Individual is assessed by a provider every 6 months for adherence to the prescribed CGM regimen and treatment plan.Every 6 months

Idaho-Specific Insulin Pump and Non-Implantable CGM Criteria

For Idaho-specific medical necessity criteria, coverage is determined under the applicable state-specific clinical coverage guidance:

Applicable Idaho-specific criteria

For insulin infusion pumps, refer to the Idaho Medicaid Provider Handbook, Provider Guidelines, Durable Medical Equipment, Prosthetics, Orthotics, and Supplies: Insulin Infusion Pumps.
The referenced Idaho Medicaid guidance supplies the medical necessity clinical coverage criteria.
For short-term and long-term non-implantable continuous glucose monitoring, refer to the DME MAC Local Coverage Determination (LCD) for Glucose Monitors (L33822).
The referenced DME MAC LCD supplies the medical necessity clinical coverage criteria.

Unproven and Not Medically Necessary Devices

The following devices are unproven and not medically necessary for managing individuals with diabetes because of insufficient evidence of efficacy or insufficient clinical evidence establishing safety and efficacy:

The following devices are unproven and not medically necessary

Implantable insulin pumps.
Nonprogrammable transdermal insulin delivery systems, including wearable, disposable systems such as V-Go.
Evidence is insufficient to establish safety and efficacy in diabetes management.
Noninvasive continuous glucose monitoring devices.
Evidence is insufficient to establish efficacy.

Implantable insulin pumps and nonprogrammable transdermal insulin delivery systems (for example, V-Go) are excluded as unproven and not medically necessary for managing individuals with diabetes because of insufficient evidence of efficacy.

The use of noninvasive continuous glucose monitoring devices is unproven and not medically necessary for managing individuals with diabetes because of insufficient evidence of efficacy.

Continuous glucose monitors that are available over the counter without a prescription, such as Dexcom Stelo, Abbott Lingo, and Abbott Libre Rio, are out of scope for this policy. These products are obtained through a local pharmacy and are not supported by mail-order durable medical equipment providers. Also refer to Benefit Considerations.

FDA approval alone is not a basis for coverage. This FDA section is provided for informational purposes only.

Implantable insulin pumps and nonprogrammable transdermal insulin delivery systems are not medically necessary for managing individuals with diabetes.

Noninvasive continuous glucose monitoring devices are not medically necessary because of insufficient evidence of efficacy.

There is insufficient evidence in the clinical literature demonstrating the safety and efficacy of nonprogrammable wearable, disposable insulin delivery devices in managing individuals with diabetes. Larger, well-designed studies with long-term follow-up and comparative effectiveness data are needed. A prospective, observational, open-label, multicenter study of V-Go included 188 participants with type 2 diabetes and suboptimal glycemic control (HbA1c ≥ 7%). At 12 months, 112 participants (60%) remained in the study; 66 used V-Go and 46 used other therapies. V-Go was associated with significantly improved glycemic control and, among most participants with prior insulin use, significantly less insulin. In total, 22 participants (12%) reported hypoglycemic events (≤ 70 mg/dL), with an event rate of 1.51 events per participant per year. Limitations included the lack of a control group and high attrition rates. Retrospective chart reviews have also reported improved glycemic control with V-Go, but are limited by retrospective design, small sample size, and/or short-term follow-up. Further well-designed, prospective studies are needed to establish the safety and efficacy of this device in managing individuals with diabetes (Hundal et al., 2020; Zeidan et al., 2020; Everitt et al., 2019; Raval et al., 2019; Sutton et al., 2018; Lajara et al., 2016; Lajara et al., 2015; Rosenfeld et al., 2012).

Billing and Diagnosis Codes

CPT CodesCPT

*0446T	Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training.
*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 of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; patient-provided equipment, sensor placement, hook-up, calibration of monitor, patient training, and printout of recording.
95250	Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; physician or other qualified health care professional (office) provided equipment, sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording.
95251	Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; analysis, interpretation, and report.

HCPCS CodesHCPCS

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 continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service.
A4239	Supply allowance for nonadjunctive, nonimplanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service.
A9274	External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories.
A9276	Sensor; invasive (e.g., subcutaneous), disposable, for use with nondurable medical equipment interstitial continuous glucose monitoring system (CGM), one unit = 1 day supply.
A9277	Transmitter; external, for use with nondurable medical equipment interstitial continuous glucose monitoring system (CGM).
A9278	Receiver (monitor); external, for use with nondurable medical equipment interstitial continuous glucose monitoring system (CGM).
E0784	External ambulatory infusion pump, insulin.
E0787	External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuous glucose sensing.
E2102	Adjunctive, nonimplanted continuous glucose monitor (CGM) or receiver.

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HCPCS CodesHCPCS

*S1031	Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor (for physician interpretation of data, use CPT code).
*S1034	Artificial pancreas device system (e.g., low glucose suspend [LGS] feature) including continuous glucose monitor, blood glucose device, insulin pump and computer algorithm that communicates with all of the devices.
*S1035	Sensor; invasive (e.g., subcutaneous), disposable, for use with artificial pancreas device system.
*S1036	Transmitter; external, for use with artificial pancreas device system.
*S1037	Receiver (monitor); external, for use with artificial pancreas device system.

ICD-10 Diagnosis CodesICD-10

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.
E11.3212	Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye.

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Applicable ICD-10-CM Type 2 Diabetes CodesICD-10

E11.3493	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral.
E11.3499	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye.
E11.3511	Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye.
E11.3512	Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye.
E11.3513	Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral.
E11.3519	Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye.
E11.3521	Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye.
E11.3522	Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye.
E11.3523	Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral.
E11.3529	Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye.

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Applicable ICD-10-CM Pregnancy and Gestational Diabetes CodesICD-10

O24.111	Pre-existing type 2 diabetes mellitus, in pregnancy, first trimester.
O24.112	Pre-existing type 2 diabetes mellitus, in pregnancy, second trimester.
O24.113	Pre-existing type 2 diabetes mellitus, in pregnancy, third trimester.
O24.119	Pre-existing type 2 diabetes mellitus, in pregnancy, unspecified trimester.
O24.12	Pre-existing type 2 diabetes mellitus, in childbirth.
O24.13	Pre-existing type 2 diabetes mellitus, in the puerperium.
O24.410	Gestational diabetes mellitus in pregnancy, diet controlled.
O24.414	Gestational diabetes mellitus in pregnancy, insulin controlled.
O24.415	Gestational diabetes mellitus in pregnancy, controlled by oral hypoglycemic drugs.
O24.419	Gestational diabetes mellitus in pregnancy, unspecified control.

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FDA Insulin Delivery Product Codesmixed

LZG	Product code for external insulin pumps
QFG	Product code for external insulin pumps
OZP	Product code for automated insulin delivery systems or hybrid closed-loop insulin pumps

FDA Continuous Glucose Monitor Product Codesmixed

MDS	Product code for continuous glucose monitors
QCD	Product code for continuous glucose monitors
QHJ	Product code for continuous glucose monitors
SBA	Product code for the Eversense 365 continuous glucose monitoring system

CPT/HCPCS Codes Not on the State of Idaho Medicaid Fee SchedulemixedNot Covered

0446T	Not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered
0448T	Not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered
S1030	Not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered
S1031	Not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered
S1034	Not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered
S1035	Not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered
S1036	Not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered
S1037	Not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered

Initial Implantable CGM Age

Minimum ageAt least 18 years

Applies toInitial long-term CGM using an implantable glucose sensor

Coverage conditionAll applicable initial implantable CGM criteria must be met

Intensive Insulin Therapy

Treatment frequencyInsulin treatment at least three times a day

Documentation, Submission, and Coverage Risks

Note

Use Applicable Idaho and DME MAC Criteria

Use the applicable Idaho Medicaid and DME MAC clinical coverage criteria when evaluating insulin infusion pumps and short- or long-term non-implantable CGM.

Insulin infusion pumps: Idaho Medicaid Provider Handbook, Durable Medical Equipment, Prosthetics, Orthotics, and Supplies: Insulin Infusion Pumps.
Short- and long-term non-implantable CGM: DME MAC LCD for Glucose Monitors (L33822).

Documentation Required

Medical Necessity Records Required

Ensure the patient’s medical record fully supports medical necessity. Records may be requested for review and do not, by themselves, guarantee coverage.

Include relevant medical history, physical examination, and pertinent diagnostic test or procedure results.
Keep documentation legible in the medical record and make it available upon request.

Clinical and Technology Background

Continuous glucose monitors measure interstitial glucose and may provide real-time readings, intermittently scanned readings, or professional pattern data. Implantable CGM uses a subcutaneously inserted sensor that communicates glucose levels wirelessly to a mobile device. Professional CGM devices are clinic-based, worn for a discrete period—generally 7–14 days—and used to assess glycemic patterns and trends.

Policy Definitions

Adjunctive Continuous Glucose Monitor

DefinitionA CGM that requires confirmation before treatment decisions

Required confirmationVerify glucose levels or trends with a blood glucose monitor

Decision pointConfirmation is required before making treatment decisions

Level 2 Hypoglycemia

DefinitionGlucose below 54 mg/dL

SI equivalent3.0 mmol/L

Clinical significanceAssociated with increased risk for cognitive dysfunction and mortality

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS024ID.E

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateNot specified

SourceLink

On This Page

Alternative treatmentUse of an insulin pump

Qualifying pathwayOne of the qualifying pathways for initial long-term implantable CGM

Recurrent Level 2 Hypoglycemia

Event thresholdMore than one level 2 hypoglycemic event

Clinical requirementEvents must persist despite multiple treatment-adjustment attempts

Qualifying contextA history of recurrent level 2 hypoglycemia is an initial implantable CGM pathway

Treatment Adjustment Attempts

Number of attemptsMore than one attempt

Permitted adjustmentAdjust medication(s)

Plan modificationModify the diabetes treatment plan

Continued Implantable CGM Reassessment

Reassessment intervalEvery 6 months

Assessed byA provider

Assessment focusAdherence to the prescribed CGM regimen and treatment plan

Level 2 Hypoglycemia Threshold

Glucose thresholdBelow 54 mg/dL

SI equivalent3.0 mmol/L

Clinical significanceAssociated with increased risk for cognitive dysfunction and mortality

Professional CGM Wear Period

Typical wear periodGenerally 7–14 days

Device settingPlaced in a health care professional's office or used with remote instruction

Use of dataAssess glycemic patterns and trends

V-Go Evidence Study

Baseline HbA1c thresholdAt least 7%

Device studiedV-Go

Study populationParticipants with type 2 diabetes and suboptimal glycemic control

Prior Authorization

Document Initial Implantable CGM Criteria

For initial long-term CGM using an implantable glucose sensor, document that all applicable criteria are met before submitting the request.

Use is consistent with FDA-labeled indications, contraindications, warnings, and precautions.
The individual is age ≥ 18 years.
The individual either requires intensive insulin therapy (insulin-treated at least three times daily or using an insulin pump) or has a level 3 hypoglycemic event or recurrent (more than one) level 2 hypoglycemic events despite multiple (more than one) medication or diabetes-treatment-plan adjustments.

Prior Authorization

Document Continued Implantable CGM Criteria

For continued long-term implantable CGM, document the ongoing qualifying indication and provider reassessment at least every 6 months.

The individual continues to require intensive insulin therapy or met the initial-use clinical criteria for hypoglycemia when CGM was initiated.
A provider assesses adherence to the prescribed CGM regimen and treatment plan every 6 months.

Unsupported block type: denial_risk。有

Denial Risk

Noninvasive CGM Not Medically Necessary

Noninvasive CGM devices are unproven and not medically necessary for diabetes management because evidence of efficacy is insufficient.

Expect an adverse coverage determination when the requested device is a noninvasive CGM.

Denial Risk

Initial Implantable CGM Denial Conditions

An initial implantable CGM request is at risk for denial when any required criterion is not met or cannot be documented.

The individual is under age 18.
Use is not within FDA-labeled indications, contraindications, warnings, or precautions.
The individual does not require intensive insulin therapy and lacks the qualifying level 3 or recurrent level 2 hypoglycemia history despite multiple treatment adjustments.

Denial Risk

Continued Implantable CGM Denial Conditions

Continued implantable CGM is at risk for denial when ongoing qualifying therapy or indication and required provider reassessment are not documented.

The individual no longer requires intensive insulin therapy and did not meet the qualifying initial hypoglycemia criteria at initiation.
A provider has not assessed adherence to the prescribed CGM regimen and treatment plan every 6 months.

Denial Risk

Insufficient Evidence for Nonprogrammable Transdermal Delivery

Do not rely on limited observational or retrospective evidence to establish coverage for nonprogrammable wearable, disposable insulin delivery devices. Insufficient evidence may result in an adverse coverage decision.

The evidence lacks adequate well-designed, long-term comparative effectiveness data.
Wearable disposable systems such as V-Go may be affected.

Note

FDA Approval Alone Does Not Establish Coverage

FDA approval or clearance alone does not establish coverage. Apply the applicable benefit terms and clinical coverage criteria in addition to confirming regulatory status.

Do not treat FDA approval alone as a basis for coverage.

Billing Rule

Over-the-Counter CGMs Are Out of Scope

CGM systems obtained over the counter without a prescription are outside the scope of this policy.

Examples include Dexcom Stelo, Abbott Lingo, and Abbott Libre Rio.
These products are obtained through a local pharmacy and are not supported by mail-order durable medical equipment providers.

Billing Rule

Codes May Not Be Covered Under Idaho Medicaid

The following CPT/HCPCS codes are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by the State of Idaho Medicaid Program.

CPT/HCPCS codes: 0446T, 0448T, S1030, S1031, S1034, S1035, S1036, and S1037.
Refer to the Idaho Medicaid Provider Handbook, General Information and Requirements for Providers: Non-Covered and Excluded Services, before submitting claims or requests involving these codes.

Level 3 Hypoglycemia

DefinitionA severe event with an altered mental and/or physical state

Assistance requiredRequires third-party assistance for treatment

Clinical urgencyLife-threatening and requires emergent treatment

Intermittently Scanned (Flash) CGM

Device componentsCombined glucose sensor/transmitter and a separate reader

MeasurementMeasures glucose levels continuously

User actionRequires scanning to visualize and store glucose values

Nonadjunctive Continuous Glucose Monitor

DefinitionA CGM usable for treatment decisions without a stand-alone blood glucose monitor

Confirmation requirementNo stand-alone blood glucose monitor is needed to confirm testing results

UseGlucose readings can directly inform treatment decisions

Professional Continuous Glucose Monitor

SettingPlaced in a health care professional's office or used with remote instruction

Wear periodWorn for a discrete period, generally 7–14 days

Ownership and purposeClinic-based rather than user-owned; data assess glycemic patterns and trends

Real-Time Continuous Glucose Monitor

Core componentsSubcutaneous sensor, external transmitter, and handheld receiver and/or smartphone

DisplayDisplays glucose readings continuously in real time

AlertsProvides audible alerts when readings are out of range

Gestational Diabetes Mellitus

DefinitionDiabetes diagnosed in the second or third trimester of pregnancy

Prior diabetes statusNot clearly overt diabetes before pregnancy

Typical courseUsually resembles type 2 diabetes and disappears after childbirth

Nonprogrammable Transdermal Insulin Delivery

Device typePatch device

Insulin deliveryDelivers preset basal and on-demand bolus doses transdermally

ProgrammabilityLacks programmability

Implantable Continuous Glucose Monitor

Sensor placementSubcutaneously inserted sensor

Sensing technologyFluorescence-sensing technology

Data transmissionCommunicates glucose levels wirelessly through a smart transmitter to a mobile device