DraftUnitedHealthcarePolicy CSNCT0347.11

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

This North Carolina–specific medical policy governs coverage references and coding for continuous glucose monitors (CGMs) and insulin delivery systems for UnitedHealthcare members in North Carolina. It directs readers to NC Medicaid clinical coverage criteria for detailed medical necessity determinations.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CSNCT0347.11

Change TypeCode removalFDA updateadministrative note removed

Effective DateNov 1, 2025

Next Review Date

Key ActionRefer to the North Carolina Medicaid Clinical Coverage Policy 5A-3 for medical necessity criteria when submitting prior authorization requests.

SourceLink

POLICY UPDATE CHANGES

Removed CPT code 0447T.

Removed notation indicating HCPCS code E0784 is not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program.

Updated FDA section to reflect the most current information, including clearance of Eversense 365 (510k) indication.

State-specificPolicy applies to

Links providedReferences to NC Medicaid clinical criteria

OTC excludedOTC CGM status

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Coverage and Medical Necessity Criteria

Delegated Medical Necessity (NC Medicaid 5A-3)

Covered when medical necessity criteria are met by the referenced North Carolina Medicaid clinical coverage policy.

Delegated criteria: Medical necessity clinical coverage criteria for adults (>20) and gestational diabetes, children (0-20), and continuous glucose monitoring are handled by the North Carolina Medicaid Clinical Coverage Policy 5A-3; UnitedHealthcare NC defers to that document for specific coverage rules.

See North Carolina Medicaid Clinical Coverage Policy 5A-3 (Nursing Equipment and Supplies) for full clinical criteria and authorization requirements.

Continuous glucose monitoring systems that are available over the counter (OTC) without a prescription — for example, Dexcom Stelo, Abbott Lingo, and Abbott Libre Rio — are out of scope for this policy. These OTC CGM products are typically obtained through local pharmacies and are not supported by mail-order durable medical equipment (DME) providers; as a result, requests for coverage under the mail-order DME benefit may be denied.

Because OTC CGM devices are acquired at retail pharmacies and do not require a prescription, they fall outside the coverage pathways described in this policy. Providers seeking reimbursement or prior authorization for CGM services should verify whether the specific device requires a prescription and is supported by mail-order DME channels before submitting a claim or authorization request.

The listing of procedure, supply, or diagnosis codes in this policy is provided for reference only. Listing a code does not imply that the service described by the code is a covered health service, guarantee reimbursement, or ensure claim payment. Coverage determinations are made according to federal, state, and contractual requirements and applicable laws; other policies and guidelines may apply.

Applicable Codes and Coding Rules

Procedure CPT/HCPCS (implantable sensor procedures)CPT

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.

Covered CPT Codes (CGM monitoring/interpretation)CPTCovered

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 Supply and Device 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 non-adjunctive, 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), 1 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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ICD-10 Diagnosis Codes (selected examples from list)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.
O24.111	Pre-existing type 2 diabetes mellitus, in pregnancy, first trimester.

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Applicable code changesmixed

0447T	CPT code removed from applicable codes list
E0784	HCPCS code previously annotated regarding NC Medicaid fee schedule; notation removed

Minimum CGM monitoring duration for CPT 95249-95250

Minimum monitoring durationCPT 95249 and 95250 require ambulatory CGM monitoring for a minimum of 72 hours.

ScopeApplies to codes 95249 (patient‑provided equipment) and 95250 (office‑provided equipment) as described in CPT instructions.

Related serviceInterpretation and report billed separately with CPT 95251 (also requires minimum 72 hours).

Actionable Provider Guidance

Documentation Required

Code Listing Does Not Guarantee Coverage or Payment

Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service, guarantee reimbursement, or assure claim payment. Benefit coverage is determined by federal, state, or contractual requirements and applicable laws; other policies and plan documents may apply. Providers should verify member benefits and prior authorization requirements before rendering services.

Providers must confirm member-specific benefits and prior authorization requirements prior to billing.
Inclusion of codes is for reference only and does not constitute a determination of coverage or payment.

Denial Risk

OTC CGM Systems Out of Scope

Continuous glucose monitoring (CGM) systems that are available over the counter (OTC) without a prescription (for example, Dexcom Stelo, Abbott Lingo, Abbott Libre Rio) are out of scope for this policy. Coverage for maintenance, replacement, or related supplies for OTC CGMs may be denied. These OTC products are typically obtained through retail pharmacies and are not supported by mail-order DME providers.

Definitions and Terminology

Over-the-counter CGM

DefinitionOver‑the‑counter (OTC) CGM: continuous glucose monitoring systems available without a prescription that are obtained through a local pharmacy.

ExamplesDexcom Stelo; Abbott Lingo; Abbott Libre Rio.

Procurement noteOTC CGMs are obtained via local pharmacies and are not supported by mail‑order DME providers under this policy.

Coverage implicationOTC CGM systems are out of scope for this policy and requests may be denied for mail‑order DME coverage.

Automated insulin delivery / hybrid closed-loop

DefinitionAutomated insulin delivery (hybrid closed‑loop): integrated systems combining a continuous glucose monitor, an insulin pump, and algorithmic control to automate insulin dosing.

Background

Continuous glucose monitors (CGMs) and insulin delivery systems — including external insulin pumps and integrated automated insulin delivery or hybrid closed‑loop systems — are device‑based therapies used to manage glucose in people with diabetes. This policy provides coding references and device examples (FDA‑cleared models) for UnitedHealthcare members in North Carolina and defers specific medical necessity determinations to the North Carolina Medicaid Clinical Coverage Policy 5A-3.

FDA‑cleared CGM models are listed for reference (examples include Abbott FreeStyle Libre series, Dexcom G6/G7, Medtronic Guardian, and Eversense systems). Note that certain CGM products that are sold over the counter without a prescription are explicitly excluded from the scope of this policy and are obtained through local pharmacies rather than mail‑order DME providers.

Revision History and Policy Changes

2025-11-01code_changeLatest

Removed CPT code 0447T from the applicable codes list.

2025-11-01notation_removal

Removed prior notation indicating HCPCS code E0784 was not on the State of North Carolina Medicaid Fee Schedule.

2025-11-01regulatory_update