ModifiedUnitedHealthcarePolicy CS024NE.AD

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

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This policy governs medical necessity criteria, coverage rationale, and coding for continuous glucose monitoring (CGM) devices and insulin delivery systems for UnitedHealthcare members in Nebraska.

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ModifiedUnitedHealthcarePolicy CS024NE.AD

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

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This policy governs medical necessity criteria, coverage rationale, and coding for continuous glucose monitoring (CGM) devices and insulin delivery systems for UnitedHealthcare members in Nebraska.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS024NE.AD

Change TypeState-referenced criteria updates and removal of long-term CGM criteria

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionRefer to Nebraska DHHS Code and Heritage Health Plan advisory for state-specific medical necessity criteria and prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

Replaced instruction to refer to the Nebraska Department of Health and Human Services Code for external insulin pumps with instruction to refer for medical necessity clinical coverage criteria.

Updated instruction to refer to Nebraska Department of Health and Human Services Code for medical necessity clinical coverage criteria of continuous glucose monitors.

Removed previous long-term CGM coverage criteria and replaced with instruction to refer to Nebraska Heritage Health Plan advisory for medical necessity criteria.

Updated Clinical Evidence and References sections to reflect the most current information.

NEState-specific application

CGM & pumpsDevice types addressed

CPT/HCPCS/ICD-10Coding included

NE DHHSState regulation cross-reference

PMCF citedEversense evidence summarized

91% / 75%Sensor life achievement

Coverage Criteria and Rationale

Coverage Rationale and State-Specific Criteria

Coverage is determined using Nebraska-specific DHHS criteria and the policy's coverage rationale.

State application: Policy applies only to State of Nebraska and follows Nebraska DHHS criteria for insulin pumps and CGMs.

See Nebraska DHHS Code references cited in document

State-referenced medical necessity: For medical necessity clinical coverage criteria of external insulin pumps, refer to Nebraska Department of Health and Human Services, Code § 471-7-004.02(EE): Insulin Infusion Pumps, External; for continuous glucose monitors, refer to Nebraska Department of Health and Human Services, Code § 471-7-004.02(Q): Continuous Glucose Monitors (CGM).

Providers must follow the referenced state codes for criteria details.

Devices considered not medically necessary: Nonprogrammable transdermal insulin delivery systems (e.g., V-Go) and implantable insulin pumps are considered unproven and not medically necessary due to insufficient evidence of safety and efficacy.

Applies per policy exclusions and evidence summaries.

Long-term CGM delegation: Long-term CGM (>14 days) medical necessity clinical coverage criteria are governed by Nebraska DHHS Heritage Health Plan: Health Plan Advisory 24-15.>14 days

Refer to Heritage Health Plan advisory for clinical criteria

Short-Term CGM (Professional) Coverage

Short-term CGM use

Short-term CGM (3-14 days): Short-term continuous glucose monitoring (professional/clinic-placed) worn for a discrete diagnostic period (generally 3–14 days) by a healthcare provider is proven and medically necessary for management of individuals with diabetes.3-14 days

Clinic-owned (professional) CGM; used for assessment of glycemic patterns; devices may be blinded or visible.

Evidence-based coverage considerations

Covered when supported by clinical evidence and applicable benefit language; document summarizes clinical evidence for insulin pumps and CGM systems and highlights limitations.

Insulin delivery considerations: Professional societies indicate insulin pumps may be considered for insulin-deficient diabetes due to other causes (e.g., cystic fibrosis–related diabetes, post-transplantation, post-pancreatectomy) though evidence is limited.

(ADA, 2025; McCall et al., 2023)

Implantable insulin pumps are available only in clinical trial settings and are not commercially available for routine coverage.

See clinical trial availability and lack of FDA-approved implantable pumps.

Nonprogrammable transdermal insulin delivery: There is insufficient evidence demonstrating the safety and efficacy of nonprogrammable wearable disposable insulin delivery devices (e.g., V-Go); further well-designed long-term comparative studies are needed.

Observational and retrospective studies report HbA1c improvements but are limited by design and attrition (Grunberger et al., 2020; others).

State-specific coverage delegation (Nebraska)

Coverage and medical necessity determinations reference state-specific criteria for Nebraska.

State-referenced coverage delegation: Medical necessity clinical coverage criteria for external insulin pumps and continuous glucose monitors are determined by referring to Nebraska Department of Health and Human Services Code § 471-7-004.02(EE) and § 471-7-004.02(Q), respectively; long-term (>14 days) CGM criteria are delegated to Heritage Health Plan: Health Plan Advisory 24-15.

Providers must follow the referenced state codes/advisories for criteria details and documentation requirements.

This policy considers nonprogrammable transdermal insulin delivery systems (for example, V-Go) and implantable insulin pumps to be unproven for management of individuals with diabetes. Clinical evidence is insufficient to demonstrate consistent safety and efficacy for these device classes, and they are therefore listed as not medically necessary under the policy's non–state-specific coverage rationale. Providers should expect coverage denials for these devices unless there is applicable state-specific guidance that explicitly supports medical necessity.

Implantable insulin pumps are currently available only in clinical trial settings and are not commercially available for routine clinical use. Because these devices are investigational outside of research contexts, implantable insulin pumps are not covered for general clinical care.

Continuous glucose monitor (CGM) products that are distributed over the counter (OTC) without a prescription (for example, Dexcom Stelo, Abbott Lingo, Abbott Libre Rio) are outside the scope of this policy. OTC CGM products are obtained through retail pharmacies and are not managed via mail-order DME channels; coverage and benefit considerations for OTC CGMs follow applicable pharmacy or benefit rules rather than this DME-oriented policy.

The policy classifies both implantable insulin pumps and nonprogrammable transdermal insulin delivery systems as unproven. The rationale is limited clinical evidence demonstrating effectiveness compared with standard insulin delivery methods; accordingly these device types are considered not medically necessary for routine diabetes management in this policy.

Available literature on nonprogrammable wearable disposable insulin delivery devices (for example, V-Go) is limited and of variable quality. Observational and retrospective studies report some HbA1c improvements, but study limitations (lack of control groups, small samples, high attrition) prevent definitive conclusions about safety and effectiveness. Larger, well‑designed prospective studies with long‑term follow up and comparative effectiveness data are needed before these devices can be considered medically necessary.

There are currently no FDA‑approved implantable insulin pumps. The absence of FDA approval for implantable insulin pumps informs coverage decisions: implantable pumps are not supported as approved devices under this policy and remain limited to investigational or clinical trial contexts.

Procedure, HCPCS, and Diagnosis Codes

Procedure 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 / DME 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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ICD-10 Codes (partial list shown in document)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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Applicable ICD-10 Diagnosis CodesICD-10

E11.3552	Type 2 diabetes mellitus with proliferative diabetic retinopathy, right eye
E11.3553	Type 2 diabetes mellitus with proliferative diabetic retinopathy, left eye
E11.3559	Type 2 diabetes mellitus with proliferative diabetic retinopathy, bilateral/unspecified
E11.3591	Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye
E11.3592	Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye
E11.3593	Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E11.3599	Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified
E11.36	Type 2 diabetes mellitus with diabetic cataract
E11.37X1	Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E11.37X2	Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye

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FDA product codes and device listingsmixed

SBA (product code)	Eversense 365 CGM system (FDA product code listed in text)
MDS, QCD, QHJ (product codes)	CGM product codes referenced for FDA information
LZG, QFG (product codes)	CGM product codes referenced for FDA information
OZP (product code)	Automated insulin delivery/hybrid closed-loop insulin pumps product code referenced for FDA information

Minimum CGM monitoring duration for CPT 95249/95250

Minimum monitoring durationCPT 95249 and 95250 require ambulatory continuous glucose monitoring for a minimum of 72 hours

Codes referenced95249 (patient-provided) and 95250 (physician/office-provided) both specify ≥72 hours of monitoring

Associated reporting code95251 covers analysis, interpretation, and report for ambulatory CGM ≥72 hours

HbA1c change reported in studies

Reported HbA1c change (single-arm cohorts)Single-arm Eversense cohorts demonstrated approximately -0.4% to -0.5% reduction in HbA1c

Provider Requirements and Authorization

Prior Authorization

State-specific prior authorization requirement (Nebraska DHHS references)

For Nebraska members, prior authorization and medical necessity decisions for external insulin pumps must follow Nebraska DHHS clinical coverage criteria by referring to Nebraska Department of Health and Human Services, Code § 471-7-004.02(EE): Insulin Infusion Pumps, External. Similarly, CGM medical necessity criteria reference Nebraska DHHS Code § 471-7-004.02(Q).

Providers must use the Nebraska DHHS code sections noted when submitting prior authorization requests for external insulin pumps and CGMs.
Long-term CGM (>14 days) medical necessity criteria are governed by the Nebraska Heritage Health Plan advisory (see Health Plan Advisory 24-15).

Prior Authorization

Refer repair/replacement prior authorization to DME/Repairs policy

Repair and replacement coverage for devices referenced in this policy is governed by UnitedHealthcare's Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for Nebraska Only) policy; prior authorization or benefit limits may apply under that policy.

Key Definitions

Adjunctive CGM — definition and implications

DefinitionAdjunctive CGM: a CGM that requires the user to verify CGM-displayed glucose levels or trends with a blood glucose monitor before making treatment decisions

Clinical implicationReadings from adjunctive CGMs are not used alone for treatment changes without confirmatory SMBG

Regulatory sourcesDefinition cites CMS and ADA guidance as referenced in policy definitions

Intermittently Scanned (Flash) CGM (isCGM) — definition

DefinitionIntermittently Scanned (Flash) CGM (isCGM): devices with a combined sensor/transmitter and a separate reader that measure continuously but require scanning for visualization and storage of glucose values; available with or without alarms

Use caseisCGM systems require the user to scan the sensor to view and store glucose data rather than continuous automatic display

Background and Evidence Summary

Continuous glucose monitoring (CGM) systems continuously measure interstitial glucose using a sensor, transmitter, and a display or receiver and are available in several classes. Real‑time CGM (rtCGM) systems provide continuous glucose readings and alerts for out‑of‑range values. Intermittently scanned (isCGM or flash) CGM requires scanning to visualize stored glucose data. Adjunctive CGMs require confirmation with a blood glucose meter before treatment decisions, whereas non‑adjunctive CGMs can be used to make treatment decisions without verification. CGMs may be provided as short‑term professional (clinic‑owned, typically 3–14 days) systems for diagnostic assessment or as personal wearable systems with disposable or implantable sensors for ongoing management.

Policy Revision History

2026-08-01policy_revisionLatest

Revised state-specific instructions: clarified Nebraska DHHS Code § 471-7-004.02(EE) should be used for medical necessity clinical coverage criteria for external insulin infusion pumps (external).

2026-08-01policy_revision

Updated Nebraska DHHS Code reference § 471-7-004.02(Q) to specify it provides medical necessity clinical coverage criteria for continuous glucose monitors (CGMs).

2026-08-01

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS024NE.AD

Change TypeState-referenced criteria updates and removal of long-term CGM criteria

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionRefer to Nebraska DHHS Code and Heritage Health Plan advisory for state-specific medical necessity criteria and prior authorization requirements.

SourceLink

On This Page

Implantable CGM (Eversense) evidence: Evidence for implantable CGM systems (Eversense) includes cohort studies, randomized trials, and registries showing moderate accuracy, reductions in HbA1c in single-arm cohorts (~0.4–0.5%), and improvements in time-in-range; however, overall evidence quality is variable and clinical utility across outcomes remains uncertain.

PROMISE, PRECISION, PRECISE II, PRECISE, ENHANCE, PMCF registry, Hayes assessment cited.

Hayes assessment and single-arm cohort studies suggest statistically significant HbA1c reductions of ~0.5% but clinical relevance is uncertain

RCT findingsOne RCT reported no difference in HbA1c between activated vs blinded Eversense groups

Time in range — reported values and thresholds

Time in range thresholdTime in range defined as ≥70–180 mg/dL

Observed Sanchez et al. valueSanchez et al. reported time in range of 62.3% in first U.S. commercial Eversense users

Other reported glycemic distributionSanchez et al. also reported >180–250 mg/dL = 21.9%, >250 mg/dL = 11.6%, <70 mg/dL = 4.1%, <54 mg/dL = 1.2%

Refer prior authorization and claims questions about repairs or replacements to the Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for Nebraska Only) policy.

Prior Authorization

Follow UHC policy plus Nebraska DHHS / Heritage Health Plan references

When making medical necessity determinations and prior authorization decisions, follow UnitedHealthcare policy together with the referenced Nebraska DHHS code sections and Heritage Health Plan advisory as applicable.

Use Nebraska Department of Health and Human Services Code § 471-7-004.02(EE) for external insulin pumps and § 471-7-004.02(Q) for CGMs.
For long-term CGM (>14 days), refer to Heritage Health Plan: Health Plan Advisory 24-15 per the policy revision notes.

Denial Risk

Requests for devices listed as unproven may be denied

Devices described in this policy as unproven (for example, nonprogrammable transdermal insulin delivery systems such as V-Go and implantable insulin pumps) are considered unproven/not medically necessary due to insufficient evidence; coverage may be denied if these devices are requested without supporting evidence.

Clinical reviewers may deny requests for devices listed as unproven or not medically necessary.
Provide robust clinical evidence if seeking coverage for these device types despite the policy designation.

Denial Risk

Nonprogrammable transdermal insulin delivery — limited evidence; expect additional documentation

Nonprogrammable transdermal insulin delivery devices (e.g., V-Go) have limited and low-quality evidence; clinical reviewers may require additional documentation or may consider such devices not medically necessary.

Studies cited are observational or retrospective with limitations (no control groups, high attrition); larger well-designed trials are needed.
Expect requests to include prior therapy history and rationale for why alternative, proven therapies are not suitable.

Step Therapy

Step therapy — no specific step requirements in this policy

No specific step therapy requirements are specified in this policy for CGMs or insulin delivery devices.

Clinical reviewers may still request documentation of prior therapies when evaluating requests for unproven devices.

Documentation Required

Maintain complete medical record documentation to support medical necessity

The patient's medical record must contain documentation that fully supports medical necessity, including relevant history, physical examination, and results of pertinent diagnostic tests or procedures; records must be legible and made available upon request.

Include prior treatment history, reasons for device selection, and objective data showing medical need.
Ensure documentation is maintained in the medical record and produced when requested for review.

Documentation Required

Use specified ICD-10 diagnosis codes for documentation

Use the extensive ICD-10 diagnosis codes listed in the policy to support medical necessity documentation when submitting prior authorization requests or claims.

Select the most specific diabetes- or complication-related ICD-10 code(s) from the policy's applicable codes to document the clinical indication.

Documentation Required

Reference federal/state/contractual requirements and document the governing authority

When applying coverage rules, reference and document any applicable federal, state (Nebraska), or contractual benefit terms; in the event of conflict, federal, state, or contractual requirements govern and may supersede this policy.

Document which federal, state, or contractual requirement was used to determine coverage for the member.
Nebraska DHHS codes and Heritage Health Plan advisory must be used where specified.

Denial Risk

Higher-priority federal/state/contractual rules govern coverage decisions

Coverage decisions, including denials, must conform to higher-priority federal, state, or contractual requirements; failure to follow applicable statutes, regulations, or contract terms may lead to denial or override of this policy's guidance.

If a conflict exists between this policy and applicable federal/state/contractual requirements, the latter govern coverage determinations.

Denial Risk

Implantable insulin pumps and nonprogrammable devices — generally not covered

Because implantable insulin pumps are only available in clinical trial settings and nonprogrammable transdermal devices are considered unproven, requests for these devices will generally be considered not medically necessary and may be denied.

Implantable insulin pumps: not commercially available; coverage not supported outside trials.
Nonprogrammable transdermal devices: insufficient evidence to establish safety and efficacy.

Device typesisCGM may be offered for long-term personal use as described in the CGM device overview

Non-Adjunctive CGM — definition

DefinitionNon-Adjunctive CGM: a CGM that can be used to make treatment decisions without confirmation by a standalone blood glucose monitor

Clinical implicationNon-adjunctive systems may be used alone for diabetes treatment decisions (no confirmatory SMBG required)

Examples / regulatory notePolicy distinguishes non-adjunctive device coding (e.g., A4239, E2103) and lists nonadjunctive CGMs among available CGM models

Professional CGM — clinic-placed short-term devices definition

DefinitionProfessional CGM: clinic-placed devices worn for a discrete period (generally 7–14 days) that are clinic-owned and may provide blinded or visible data used to assess glycemic patterns and trends

Typical durationGenerally used for 7–14 day monitoring periods for diagnostic assessment

OwnershipProfessional CGM devices are clinic-owned rather than owned by the patient

Real-Time CGM (rtCGM) — systems with alerts and real-time display

DefinitionReal-Time CGM (rtCGM): systems with a sensor, transmitter, and receiver/smartphone that display continuous glucose readings in real time and provide audible alerts for out-of-range values

FunctionalityrtCGM systems continuously display glucose and generate alerts; some systems require user calibration

Use caseDesigned for long-term personal use allowing individuals to take action based on displayed data

Hypoglycemia levels — Level 2 and Level 3 definitions

Hypoglycemia Level 2Level 2 hypoglycemia: glucose <54 mg/dL (3.0 mmol/L); associated with increased risk for cognitive dysfunction and mortality

Hypoglycemia Level 3Level 3 hypoglycemia: a severe event with altered mental and/or physical state requiring third-party assistance; life-threatening and requires emergent treatment

SourceDefinitions cited from ADA (2025) and supporting references in the policy

Continuous Glucose Monitor (CGM) — overall device class definition

DefinitionContinuous Glucose Monitor (CGM): devices that continuously monitor interstitial glucose levels and include a sensor, transmitter, and receiver; available as short-term professional devices or long-term personal systems (rtCGM and isCGM) with disposable or implantable sensors

Sensor typesAvailable sensors may be disposable (transcutaneous) or implantable (e.g., Eversense) with smart transmitter and mobile application

Clinical rolesCGMs support ongoing glycemic assessment, time-in-range metrics, and may be used for treatment decisions depending on device labeling

Insulin delivery systems — includes external pumps, patch pumps, and nonprogrammable transdermal devices

DefinitionInsulin delivery systems include standard external insulin pumps (with tubing and infusion sets), patch pumps (e.g., OmniPod), and preset nonprogrammable transdermal devices (e.g., V-Go) as well as implantable pumps (currently only in clinical trials)

Device examplesExamples listed include conventional programmable pumps and patch devices; nonprogrammable transdermal devices lack programmability

Coverage noteNonprogrammable transdermal devices and implantable insulin pumps are described as unproven or limited to clinical trial settings in the policy

Implantable CGM — definition and example (Eversense)

DefinitionImplantable CGM: a glucose sensor implanted subcutaneously that provides continuous glucose measurements for an extended period (examples include the Eversense systems)

Sensor longevityImplantable sensors are available with intended lives such as 90, 180, or up to 365 days (Eversense 365 cleared for up to 1 year)

ComponentsImplantable CGM systems include an implanted sensor, a smart transmitter, and a mobile application to transmit readings

Implantable insulin pump — definition and FDA approval note

DefinitionImplantable insulin pump: an insulin delivery device placed internally to deliver insulin (controlled remotely); the policy notes that no implantable insulin pumps have received FDA approval at this time

Regulatory statusImplantable insulin pumps are only available in clinical trial settings and are not FDA-approved for general use

Coverage implicationBecause no FDA-approved implantable insulin pumps exist, they are considered investigational/not covered outside clinical trials per the policy

Removed prior long-term CGM (>14 days) coverage criteria and replaced them with instruction to refer to Nebraska DHHS Heritage Health Plan: Health Plan Advisory 24-15 for medical necessity criteria for long-term CGM (>14 days).

2026-08-01supporting_information_update

Updated Clinical Evidence and References sections to reflect the most current information and archived previous policy version CS024NE.AC.