ModifiedUnitedHealthcarePolicy CS024KS.03

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

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Policy governing coverage and clinical criteria for continuous glucose monitors (CGMs) and insulin delivery devices for members in Kansas; references Kansas Medical Assistance Program criteria and applies only to Kansas.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS024KS.03

Change TypeDocumentation clarification and reference updates

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review Date

Key ActionFollow the Kansas Medical Assistance Program Durable Medical Equipment Fee-for-Service Provider Manual when requesting prior authorization for CGMs and insulin pumps.

SourceLink

POLICY UPDATE CHANGES

Medical Records Documentation Used for Reviews: added language clarifying that medical records documentation may be required to assess whether the member meets clinical criteria and must fully support medical necessity.

Updated FDA and References sections to reflect the most current information.

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ModifiedUnitedHealthcarePolicy CS024KS.03

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

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Sign up for UnitedHealthcare Policy CS024KS.03 alerts

Get alerted when Policy CS024KS.03 changes without checking for updates manually.

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Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS024KS.03

Change TypeDocumentation clarification and reference updates

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review Date

Key ActionFollow the Kansas Medical Assistance Program Durable Medical Equipment Fee-for-Service Provider Manual when requesting prior authorization for CGMs and insulin pumps.

SourceLink

POLICY UPDATE CHANGES

Updated FDA and References sections to reflect the most current information.

Kansas-onlyjurisdiction

KMAPprimary criteria

CPT/HCPCS/ICDcode lists

1 yearEversense 365 duration

excludedOTC CGMs

Coverage and Medical Necessity Criteria

Primary coverage criteria (see KMAP manual)

Covered when ALL of the following are met:

Primary requirement: Coverage for continuous glucose monitors (CGMs) and insulin pumps is determined by the medical necessity criteria in the Kansas Medical Assistance Program: Durable Medical Equipment Fee-for-Service Provider Manual.

Providers must follow the KMAP DME Fee‑for‑Service Provider Manual to determine specific eligibility, documentation, and prior authorization requirements.

CGM systems that are available over the counter, without a prescription (for example, Dexcom Stelo, Abbott Lingo, Abbott Libre Rio) are out of scope for this policy. These products are typically obtained through a local pharmacy and are not supported by mail-order durable medical equipment (DME) providers.

Over-the-counter continuous glucose monitoring (OTC CGM) products—such as Dexcom Stelo, Abbott Lingo, and Abbott Libre Rio—are excluded from coverage under this policy. OTC CGMs are acquired via local pharmacies rather than through mail-order DME channels and therefore fall outside the scope of this policy.

Information about FDA-cleared or FDA-approved CGM devices is provided for reference only. FDA approval alone is not a basis for coverage, and inclusion in the FDA section of this policy does not by itself establish medical necessity or guarantee coverage.

Coding: CPT, HCPCS, ICD-10, and Device References

Specified 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.

Ambulatory CGM CPT CodesCPT

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/S Codes and E-CodesHCPCS

A4226	Supplies for maintenance of insulin infusion pump with dosage rate adjustment using therapeutic continuous glucose sensing, per week.
A4238	continuous glucose sensing, per week 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.

1–10 of 17

1/2

Selected ICD-10 Codes (Type 2 and gestational diabetes examples)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.
O24.414	Gestational diabetes mellitus in pregnancy, insulin controlled.
O24.424	Gestational diabetes mellitus in childbirth, insulin controlled.

FDA product codes referencedmixed

MDS, QCD, QHJ	FDA product codes referenced for CGM information
SBA	FDA product code for Eversense 365 CGM system (510(k) clearance referenced)

Ambulatory CGM minimum monitoring duration

Minimum monitoring durationAmbulatory CGM services (CPT 95249-95251) require monitoring for a minimum of 72 hours.

Applicable CPT codes95249, 95250, 95251 (ambulatory CGM service descriptions specify the 72-hour minimum).

Service components referencedIncludes sensor placement, hook-up, calibration, patient training, removal (when provided by office), and recording/analysis as described in CPT code text.

Eversense 365 duration

Maximum system durationEversense 365 CGM system is indicated for continually measuring glucose levels for up to 1 year.

Provider Responsibilities, Documentation, and Decision Sources

Prior Authorization

Follow Kansas Medical Assistance Program criteria

Coverage and medical necessity criteria for CGMs and insulin pumps are governed by the Kansas Medical Assistance Program: Durable Medical Equipment Fee‑for‑Service Provider Manual; providers must follow that manual when requesting prior authorization.

Use KMAP durable medical equipment manual to determine specific eligibility and documentation requirements for prior authorization requests.

Note

Check federal/state/contractual rules; InterQual primary criteria

Before relying on this policy, check applicable federal, state, or contractual benefit requirements because they govern coverage; InterQual is used for primary clinical criteria and UnitedHealthcare policies approved by KDHE may be applied when InterQual lacks criteria.

If there is a conflict, federal, state, or contractual requirements for benefit plan coverage govern.
InterQual® is the primary source for medical/surgical criteria; UHC KDHE‑approved policies may be used if InterQual lacks applicable criteria.

Background and Scope

Continuous glucose monitoring (CGM) systems and insulin delivery devices are tools used to manage blood glucose levels in people with diabetes. This policy directs providers to the Kansas Medical Assistance Program: Durable Medical Equipment Fee‑for‑Service Provider Manual for the specific medical necessity criteria that determine coverage for CGMs and insulin pumps. Examples of FDA‑listed CGM models are provided for informational purposes, and implantable systems such as the Eversense 365 are noted with their approved up to 1 year sensor duration, but eligibility and prior authorization requirements must follow the KMAP manual.

Definitions and Code Explanations

Implantable interstitial glucose sensor procedures (0446T, 0448T)

0446TCreation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training.

0448TRemoval of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation.

Procedure scopeCodes describe insertion and removal/reinsertion of implantable interstitial glucose sensors and include activation/training components.

Ambulatory continuous glucose monitoring (95249-95251)

95249Ambulatory continuous glucose monitoring via subcutaneous sensor for a minimum of 72 hours; patient‑provided equipment, sensor placement, hook‑up, calibration, patient training, and printout of recording.

95250

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS024KS.03

Change TypeDocumentation clarification and reference updates

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review Date

Key ActionFollow the Kansas Medical Assistance Program Durable Medical Equipment Fee-for-Service Provider Manual when requesting prior authorization for CGMs and insulin pumps.

SourceLink

On This Page

FDA clearanceEversense 365 (product code SBA) received 510(k) clearance on September 16, 2024.

Intended useIndicated for individuals 18 years or older and may replace finger-stick blood glucose measurements for diabetes treatment decisions.

Eversense 365 sensor duration

Sensor lifespanEversense 365 implantable sensor duration: up to 1 year per implanted sensor.

Indication ageIndicated for use in individuals 18 years or older.

ReplacementCan be used alone or with digitally connected devices for diabetes management; sensor replaced per manufacturer/FDA labeling up to yearly.

Documentation Required

Include complete medical records with requests

Ensure all documentation used to request services is included in the patient's medical record and is available upon request to support review of medical necessity.

Documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage.

Documentation Required

Ensure records are legible and demonstrate criteria met

Provide legible medical records that fully support medical necessity and demonstrate the member meets clinical criteria for the requested CGM or insulin delivery service.

UnitedHealthcare may request records to verify coverage; failure to provide required documentation may impede prior authorization or coverage determination.

Documentation Required

Required medical record documentation (history, exam, diagnostic results)

Document relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures in the patient's medical record to support medical necessity.

Examples include diabetes history, glycemic control data, and diagnostic test results referenced in the record.

Documentation Required

Documentation must support medical necessity and member meeting criteria

Medical record documentation must fully support the medical necessity of the requested services and show that the member meets the clinical criteria for coverage.

Documentation should be maintained in the patient's medical record and made available upon request.

Denial Risk

Documentation insufficiency may cause denial

Lack of medical record documentation that supports medical necessity may lead to denial of the requested services.

Incomplete or missing clinical history, exam findings, or diagnostic results can result in denial.

Denial Risk

Documentation-related denial risk for illegible or insufficient records

Failure to provide legible medical record documentation that fully supports medical necessity and that the member meets clinical criteria may result in denial or inability to confirm coverage.

Ensure all submitted records are legible and readily accessible upon request to avoid denial.

Ambulatory CGM via subcutaneous sensor for a minimum of 72 hours; office‑provided equipment, sensor placement, hook‑up, calibration, patient training, removal of sensor, and printout of recording.

95251Ambulatory CGM analysis, interpretation and report (associated with the minimum 72‑hour monitoring period).

Eversense 365 — implantable CGM system description and duration

System descriptionEversense 365 is an implantable continuous glucose monitoring system indicated for continual glucose measurement for up to 1 year.

Regulatory statusProduct code SBA; received 510(k) clearance on September 16, 2024.

Clinical useIndicated to replace finger‑stick blood glucose measurements for diabetes treatment decisions and may be used alone or with digitally connected devices.

OTC CGM systems — definition and examples

DefinitionOTC CGM systems are continuous glucose monitor products available without a prescription and obtained through a local pharmacy rather than mail‑order DME.

ExamplesExamples include Dexcom Stelo, Abbott Lingo, Abbott Libre Rio (these are out of scope for this policy).

Coverage scopeOTC CGM systems are out of scope for this policy and are not supported by mail‑order durable medical equipment providers.