UnitedHealthcare CGM Insulin Pump Coverage Update

Coverage Criteria for CGMs and External Insulin Delivery

External insulin infusion pumps

Covered when consistent with FDA labeling and InterQual criteria or Pennsylvania Medical Assistance Handbook, as applicable

External insulin pumps (general): External continuous subcutaneous insulin infusion pumps are medically necessary when used according to FDA-labeled indications, contraindications, warnings, and precautions and when medical necessity is met per InterQual CP: Durable Medical Equipment, Continuous Glucose Monitors, Insulin Pumps and Automated Insulin Delivery Technology.per FDA labeling and InterQual criteria

Refer to InterQual criteria for detailed clinical conditions.

State-specific coverage (Pennsylvania)

State-specific coverage per Pennsylvania Medical Assistance Handbook

Tubeless insulin delivery devices: Coverage guidelines for tubeless insulin delivery devices (e.g., OmniPod, CeQur, V-Go) are governed by the Pennsylvania Medical Assistance Handbook: Prior Authorization of Pharmaceutical Services.

See referenced handbook for criteria and prior authorization requirements.

Continuous glucose monitoring: Coverage guidelines for continuous glucose monitoring (CGM) products are governed by the Pennsylvania Medical Assistance Handbook: Prior Authorization of Pharmaceutical Services.

See referenced handbook for state-specific prior authorization and clinical criteria.

Not medically necessary / Unproven devices

Not medically necessary when evidence is insufficient

Implantable insulin pumps are considered unproven and not medically necessary for routine management of individuals with diabetes; currently available only in the context of clinical trials.clinical trial enrollment

No implantable insulin pumps have received FDA approval at this time.

Nonprogrammable transdermal devices: Nonprogrammable wearable disposable transdermal insulin delivery systems (other than devices specifically listed) are considered unproven and not medically necessary due to insufficient evidence of safety and efficacy.insufficient evidence

Larger, well-designed studies with long-term follow-up are needed.

Coverage overview

Covered when device type and evidence/supporting indications are met

External continuous subcutaneous insulin infusion pumps are considered proven and medically necessary in certain circumstances when used according to FDA-labeled indications, contraindications, warnings, and precautions.per FDA labeling

Revised policy language affirms coverage when FDA labeling and clinical criteria are met.

Insulin pumps for diabetes due to other causes: Insulin pumps may be considered for specific types of diabetes due to other causes (e.g., cystic fibrosis–related diabetes, post-transplantation diabetes, diabetes following pancreatic surgery) when insulin deficiency requires multiple daily injections; evidence is limited and use should follow clinical judgment and professional society guidance.clinical judgment and society guidance

Supported by ADA and literature citations.

Implantable insulin pumps are available only within clinical trial settings and are not standardly available for coverage.

Implantable insulin pumps and nonprogrammable transdermal insulin delivery systems other than those listed in this policy are considered unproven and not medically necessary due to insufficient evidence of efficacy. The policy explicitly lists implantable insulin pumps as unproven and not medically necessary and excludes other nonprogrammable transdermal systems not otherwise specified in the policy. See Benefit Considerations for related guidance.

Continuous glucose monitor (CGM) products 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 systems are obtained through local retail pharmacies and are not supported via mail‑order durable medical equipment (DME) providers; coverage requests for these OTC products may therefore be denied under this policy.

Implantable insulin pumps are not covered as standard therapy and are identified in this policy as unproven and not medically necessary for the management of individuals with diabetes because current evidence is insufficient to demonstrate efficacy. The policy notes that implantable pumps are not part of routine coverage and are only available in the context of clinical trials.

Nonprogrammable wearable disposable insulin delivery devices are considered to have insufficient evidence of safety and efficacy for routine diabetes management. The policy states that larger, well‑designed studies with long‑term follow‑up and comparative effectiveness data are needed before these devices can be supported for routine coverage.

Applicable Codes

Applicable CPT/HCPCS (sensors and CGM CPTs)mixed

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

Durable medical equipment HCPCSHCPCS

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

Additional HCPCS/S codesHCPCS

E0787	External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuous glucose sensing
E2102	Adjunctive, nonimplanted continuous glucose monitor (CGM) or receiver
E2103	Nonadjunctive, nonimplanted continuous glucose monitor (CGM) or receiver
S1030	Continuous noninvasive glucose monitoring device, purchase (For physician interpretation of data, use CPT code)
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

Representative ICD-10 diagnosis codes (full list in policy)ICD-10

E11.9	Type 2 diabetes mellitus without complications
E11.65	Type 2 diabetes mellitus with hyperglycemia
E11.649	Type 2 diabetes mellitus with hypoglycemia without coma
O24.414	Gestational diabetes mellitus in pregnancy, insulin controlled
O24.434	Gestational diabetes mellitus in the puerperium, insulin controlled

FDA product codes and device codesmixed

product code LZG or QFG	External insulin pumps information on FDA PMN site
product code OZP	Automated insulin delivery systems or hybrid closed-loop insulin pumps information on FDA PMA site
product code MDS, QCD or QHJ	CGM information on FDA PMA site
SBA	Eversense 365 CGM system 510(k) clearance product code

Minimum CGM wear duration for CPT codes 95249-95251

Minimum wear time>= 72 hours

Applicable CPT codes95249, 95250, 95251

Code descriptionsAmbulatory CGM via subcutaneous sensor for a minimum of 72 hours (includes placement, calibration, training, printout; 95251 = analysis/interpretation/report)

Eversense 365 duration

DeviceEversense 365 CGM system (product code SBA)

FDA-cleared duration

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for tubeless insulin delivery devices (e.g., OmniPod, CeQur, V-Go) per the Pennsylvania Medical Assistance Handbook: Prior Authorization of Pharmaceutical Services. Refer to the handbook for state-specific prior authorization processes and any PA-only requirements.

Affected products: tubeless insulin delivery devices (OmniPod, CeQur, V-Go)

Prior Authorization

CGM Prior Authorization and Scope

Prior authorization is also required for continuous glucose monitoring (CGM) products per the Pennsylvania Medical Assistance Handbook: Prior Authorization of Pharmaceutical Services. Requests for 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 and may be denied; these OTC CGMs are obtained through local pharmacies and are not supported by mail-order DME providers.

Out-of-scope OTC CGMs: Dexcom Stelo; Abbott Lingo; Abbott Libre Rio

Background

Diabetes mellitus encompasses several categories, including type 1 (autoimmune beta‑cell destruction leading to absolute insulin deficiency), type 2 (progressive loss of beta‑cell insulin secretion often with insulin resistance), gestational diabetes, and diabetes due to other specific causes. Poor glycemic control increases the risk of cardiovascular, renal, retinal, neurologic, and other complications, while improved glycemic control slows progression. Glycemic status is commonly assessed using blood glucose monitoring, continuous glucose monitoring (CGM), and hemoglobin A1c testing.

Definitions

Type 1 diabetes definition

DefinitionAutoimmune beta-cell destruction usually leading to absolute insulin deficiency; includes latent autoimmune diabetes in adults (LADA)

Typical implicationOften requires insulin therapy and may present in children or adults (LADA may be misdiagnosed as type 2)

Source classificationPer ADA (2025) classification of diabetes mellitus

Type 2 diabetes definition

DefinitionNon-autoimmune progressive loss of adequate beta-cell insulin secretion, frequently on a background of insulin resistance and metabolic syndrome

Typical implicationOften managed initially with lifestyle and oral agents; may progress to require insulin

Policy Revision History

2026-03-01policy_revisionLatest

Revised coverage rationale language clarifying that external continuous subcutaneous insulin infusion pumps are proven and medically necessary in certain circumstances when used according to FDA-labeled indications, contraindications, warnings, and precautions; added language that benefit coverage is determined by federal, state, or contractual requirements and applicable laws; noted that medical records may be required to assess clinical criteria but do not guarantee coverage; removed CPT code 0447T from Applicable Codes; updated FDA and references sections; archived prior policy version CS025PA.AF.

OpenPayer

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