CurrentUnitedHealthcarePolicy CS366OH.E

Continuous Glucose Monitor (for Ohio Only)

Medical policy governing coverage and clinical criteria for continuous glucose monitors (CGMs) for UnitedHealthcare members in Ohio; applies to DME and related supplies and suppliers subject to Ohio Administrative Code.

Policy Summary

PayerUnitedHealthcare

PolicyContinuous Glucose Monitor (for Ohio Only)

Policy CodePolicy CS366OH.E

Change TypeCodes added and removedinformational and layout updates

Effective DateNov 1, 2025

Next Review Date

Key ActionWhen requesting prior authorization for CGMs and supplies, follow Ohio Administrative Code 5160-10-36 and referenced DME rules.

SourceLink

POLICY UPDATE CHANGES

Added HCPCS codes A4239 and E2103 to Applicable Codes.

Removed CPT/HCPCS codes 0447T, G0564, and G0565 from Applicable Codes.

Updated FDA and References sections to reflect most current information.

Removed Description of Services section.

2025-11-01effective date

CS366OH.Epolicy identifier

Ohiostate-specific

A4239, E2103, A4238...codes listed

Policy Summary

PayerUnitedHealthcare

PolicyContinuous Glucose Monitor (for Ohio Only)

Policy CodePolicy CS366OH.E

Change TypeCodes added and removedinformational and layout updates

Effective DateNov 1, 2025

Next Review Date

Key ActionWhen requesting prior authorization for CGMs and supplies, follow Ohio Administrative Code 5160-10-36 and referenced DME rules.

SourceLink

On This Page

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Coverage Criteria (Ohio Administrative Code)

Initial Coverage Criteria (defer to OAC)

Covered when ALL of the following are met per Ohio Administrative Code 5160-10-36

State OAC medical necessity: Member meets medical necessity criteria specified in Ohio Administrative Code 5160-10-36 for continuous glucose monitorsrefer to OAC text

Specific clinical entry criteria (e.g., insulin use, hypoglycemia history) are in OAC rule and not restated here

This policy does not apply to over-the-counter (OTC) continuous glucose monitor (CGM) systems that are available without a prescription. Examples of OTC products out of scope include Dexcom Stelo, Abbott Lingo, and Abbott Libre Rio. These devices are obtained through retail pharmacies and are not supported by mail-order DME suppliers; therefore requests for coverage under this DME policy should not be submitted for OTC CGMs.

Services or items described in requests as unproven or that do not meet applicable coverage or quantity limits established by the Ohio Administrative Code may be evaluated and determined to be not medically necessary. Providers should reference the Ohio Administrative Code rules cited in this policy when preparing documentation and prior authorization requests; failure to meet OAC requirements can be a basis for denial.

Applicable Codes and Billing Guidance

Applicable 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

Applicable HCPCS / Supply CodesHCPCS

A4238	Supply allowance for adjunctive 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.
A9276	Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, 1 unit = one day supply.
A9277	Transmitter; external, for use with interstitial continuous glucose monitoring system.
A9278	Receiver (monitor); external, for use with interstitial continuous glucose monitoring system.
E2102	Adjunctive continuous glucose monitor 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).

inv-06: Minimum monitoring duration for ambulatory CGM CPT codes — >= 72 hours

Minimum monitoring duration>= 72 hours for ambulatory CGM CPT codes 95249, 95250, 95251

CPT codes referenced95249, 95250, 95251 (each specifies minimum of 72 hours)

Scope noteDuration requirement applies to ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor

Provider Requirements and Operational Notes

Prior Authorization

Prior Authorization Required

Prior authorization for services covered under this policy must follow Ohio Administrative Code (OAC) criteria. Providers should reference OAC 5160-10-36 for coverage and medical necessity determinations related to continuous glucose monitors and related DMEPOS items.

Apply OAC criteria when submitting prior authorization requests
Ensure documentation demonstrates medical necessity per OAC 5160-10-36

Note

Clinical Criteria Source

UnitedHealthcare uses InterQual as the primary source for clinical medical necessity criteria. If InterQual does not contain applicable criteria, UnitedHealthcare may apply its own Medical Policies, Coverage Determination Guidelines, and Utilization Review Guidelines that have been approved by the Ohio Department for Medicaid Services.

InterQual is primary clinical criteria source
Fallback: UHC Medical Policies/Coverage Determination Guidelines/Utilization Review Guidelines (ODMS-approved)

Definitions and Device Classifications

inv-12: Adjunctive vs Nonadjunctive CGM — HCPCS descriptors differentiate adjunctive (A4238/E2102) vs nonadjunctive nonimplanted (A4239/E2103) and implantable sensors

Adjunctive HCPCS descriptorsA4238 / E2102 — supply allowance or descriptor for adjunctive continuous glucose monitor or receiver

Nonadjunctive (nonimplanted) HCPCS descriptorsA4239 / E2103 — supply allowance or descriptor for nonadjunctive, nonimplanted continuous glucose monitor or receiver

Implantable sensor distinctionImplantable interstitial glucose sensors have separate CPT procedure codes (0446T, 0448T) rather than the HCPCS supply codes

OTC exclusion noteOTC CGM systems (e.g., Dexcom Stelo, Abbott Lingo, Abbott Libre Rio) are out of scope for this policy

inv-13: Implantable CGM — implantable sensor CPT codes for insertion/removal and device examples

Background

Continuous glucose monitors (CGMs) measure interstitial glucose levels and are used in the management of diabetes. Some CGM systems are cleared to replace fingerstick blood glucose measurements for treatment decisions and may be used alone or with connected devices. The policy references Ohio Administrative Code, Rule 5160-10-36 for medical necessity clinical coverage criteria for DME CGMs and notes FDA-cleared models (for example, Abbott FreeStyle Libre series, Dexcom G6/G7, Medtronic Guardian Connect, and implantable/long‑wear systems such as Eversense). When considering coverage, providers must follow the OAC rules for DME general provisions and CGM-specific criteria.