ModifiedUnitedHealthcarePolicy CS024IN.14

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

Medically necessary criteria and coverage guidance for continuous glucose monitors (short-term, long-term, implantable) and external insulin delivery pumps for Indiana Community Plan members.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS024IN.14

Change TypeMaterial coverage revisions and coding updates

Effective DateApr 1, 2026

Next Review Date

Key ActionUse InterQual CP for medical necessity criteria and ensure prior authorization and documentation requirements are met for non-preferred Indiana CGM products.

SourceLink

POLICY UPDATE CHANGES

Added language to indicate short-term CGM use by a healthcare provider for diagnostic purposes is proven and medically necessary for managing individuals with diabetes.

Revised medical necessity clinical coverage criteria for non-implantable CGM Intensive Insulin Therapy and added medically necessary criteria for initial long-term CGM for select non-intensive treatment plan patients with documented hypoglycemia.

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

Added requirements clarifying that medical records documentation may be required to assess clinical criteria and must fully support medical necessity.

3-14 daysShort-term CGM

up to 6 monthsInitial long-term auth

up to 12 months

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IndianaState-limited

Coverage Criteria for CGM and Insulin Delivery

InterQual-based coverage for insulin pumps and non-implantable CGM

External insulin pumps and non-implantable CGM are covered when InterQual criteria are met; see InterQual CP for detailed clinical criteria.

InterQual-based coverage: Use InterQual CP: Durable Medical Equipment, Continuous Glucose Monitors, Insulin Pumps, and Automated Insulin Delivery Technology for medical necessity clinical coverage criteria for external insulin pumps and non-implantable CGM (initial and continuation).

Refer to InterQual for specifics

Long-term CGM for non-intensive diabetes therapy (Initial)

Long-term CGM for non-intensive therapy is covered only under specific hypoglycemia criteria.

Non-intensive therapy long-term CGM: Individual is on a non-intensive diabetes treatment plan (e.g., basal insulin and/or oral medications) AND has a history of a level 3 hypoglycemic event OR recurrent (>1) level 2 hypoglycemic events that persist despite >1 attempts to adjust medications and/or modify treatment plan.history of level 3 or recurrent level 2 hypoglycemia after >1 treatment adjustments

If criteria not met, long-term CGM is not medically necessary for non-intensive therapy.

Short-term CGM (Diagnostic)

Short-term CGM:

Short-term CGM diagnostic use: Use by a healthcare provider for diagnostic purposes for a period of 3-14 days.3-14 days

Proven and medically necessary for diagnostic purposes.

External continuous subcutaneous insulin infusion pumps

Insulin pump coverage:

External subcutaneous insulin infusion pumps: External continuous subcutaneous insulin infusion pumps are medically necessary when used according to FDA labeled indications, contraindications, warnings, and precautions and per InterQual criteria; medically necessary for individuals requiring intensive insulin therapy (insulin-treated at least 3 times a day) including diabetes due to other causes (e.g., cystic fibrosis-related diabetes, post-transplantation diabetes, post-pancreatic surgery).

Refer to InterQual for precise indications and documentation requirements.

Device-specific availability and evidence

Availability and evidence stance summarized

Implantable insulin pumps are currently available only in clinical trial settings.

Implantable pumps are not generally available; use limited to trials.

Nonprogrammable transdermal insulin delivery: Insufficient evidence exists to demonstrate safety and efficacy of nonprogrammable wearable disposable insulin delivery devices (e.g., V-Go) for diabetes management; further well-designed prospective studies are needed.

Existing observational studies show some HbA1c improvements but have design limitations.

CGM clinical evidence

Evidence for CGM in non-intensive therapy and type 2 diabetes

CGM benefit in non-intensive T2D: Systematic reviews and meta-analyses (Ferreira 2024; Jancev 2024) show CGM use vs BGM in type 2 diabetes not using insulin improves HbA1c, time in range, and reduces hyperglycemia; evidence limited by small trials and short follow-up.

ECRI updated 2025 to favorable based on recent RCT meta-analysis.

Insulin pump consideration for other-cause diabetes

Use in specific diabetes etiologies

Insulin pumps for other-cause diabetes: Professional societies state insulin pumps may be considered for specific types of diabetes due to other causes (e.g., cystic fibrosis-related, post-transplant, post-pancreatic surgery) when insulin deficiency necessitates multiple daily injections, though evidence is limited.

Consider case-by-case; cite ADA and McCall 2023.

Coverage criteria (initial and short-term CGM; non-intensive regimen caveats)

Policy coverage stance and specific clinical criteria (as revised):

Short-term CGM diagnostic use: Short-term CGM (3-14 days) used by a healthcare provider for diagnostic purposes is proven and medically necessary for managing individuals with diabetes.3-14 days

Added 04/01/2026

Initial long-term CGM for non-intensive treatment plan: Initial long-term CGM is medically necessary for individuals on non-intensive regimens (e.g., basal insulin and/or oral medications) who have a history of a level 3 hypoglycemic event or recurrent (more than one) level 2 hypoglycemic events that persist despite multiple (more than one) attempts to adjust medications and/or modify the diabetes treatment plan.history of level 3 or recurrent level 2 hypoglycemia after >1 treatment adjustments

Added/clarified in policy revision

Long-term CGM for non-intensive therapy - not routine:

Implantable insulin pumps and nonprogrammable transdermal insulin delivery systems (for example, V-Go) are considered unproven and not medically necessary due to insufficient evidence of safety and efficacy. External continuous subcutaneous insulin infusion pumps remain medically necessary when used according to FDA labeling and applicable clinical criteria (see InterQual reference), but implantable pumps are not generally available outside of clinical trials and nonprogrammable transdermal products lack high-quality comparative data to support routine coverage.

For implantable glucose sensors (for example, Eversense), refer to the Indiana Health Coverage Programs Bulletin BT202520 for state-specific medical necessity criteria and program guidance. The policy also documents Eversense 365 as an FDA‑cleared implantable-duration CGM (510k K241335) with indications and regulatory details available via the FDA PMN site.

There are no FDA‑approved noninvasive continuous glucose monitors on the market at this time. Because FDA‑cleared noninvasive CGM devices do not exist, noninvasive CGM products are not covered under this medical necessity policy.

Continuous glucose monitor 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 medical necessity policy. These OTC products are obtained through local pharmacies and are not managed or supported by mail‑order durable medical equipment providers under this policy.

Long‑term CGM is medically necessary for individuals on a non‑intensive diabetes treatment plan (for example, basal insulin and/or oral medications) only when the member has a history of a level 3 hypoglycemic event or recurrent (more than one) level 2 hypoglycemic events that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan. For other indications in non‑intensive regimens, long‑term CGM is considered unproven and not medically necessary.

Nonprogrammable wearable disposable insulin delivery devices currently lack sufficient high‑quality evidence demonstrating safety and effectiveness. Existing observational and retrospective studies (for example V‑Go) have design limitations and do not establish comparative effectiveness; therefore these devices are considered investigational/not medically necessary until further well‑designed prospective data are available.

Restating the coverage position: for individuals on a non‑intensive diabetes treatment plan, long‑term CGM is medically necessary only for the specified hypoglycemia indications (history of level 3 hypoglycemia or recurrent level 2 hypoglycemia after >1 treatment adjustments). The policy revision clarifies that long‑term CGM is not routine for other indications in non‑intensive regimens and that medical record documentation may be required to support the clinical criteria.

Applicable Codes, Duration, and Coding Details

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 Level II 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

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.

Applicable ICD-10 Codes (partial 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.

Applicable ICD-10 Diagnosis CodesICD-10

E11.3313	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3319	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
E11.3391	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E11.3392	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E11.3393	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3399	Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3411	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E11.3412	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
E11.3413	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3419	Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye

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Applicable / referenced regulatory and billing codesmixed

product codes LZG or QFG	External insulin pumps information (FDA PMN site) referenced
product code OZP	Automated insulin delivery systems or hybrid closed-loop insulin pumps (FDA PMA site) referenced
product code SBA	Eversense 365 CGM system (FDA 510k - K241335)
0447T	Removed from Applicable Codes
G0564	Removed from Applicable Codes
G0565	Removed from Applicable Codes

inv-22: Short-term CGM duration — diagnostic duration window

Diagnostic durationShort-term CGM use by a healthcare provider for diagnostic purposes: 3–14 days.

PurposeUsed for diagnostic assessment of glycemic patterns and trends when ordered/managed by a healthcare provider.

Medical necessity stancePolicy states short-term CGM diagnostic use is proven and medically necessary.

inv-23: Initial long-term CGM authorization duration — initial authorization timeframe

Initial authorization periodInitial long-term CGM authorization: up to 6 months.

Prior Authorization, Documentation, and Operational Notes

Prior Authorization

Prior Authorization Required

Prior authorization is required for non-preferred Indiana continuous glucose monitoring (CGM) products and related devices. Requests for non-preferred CGM devices must meet the coverage criteria in this policy regardless of whether the request is submitted through UnitedHealthcare prior authorization channels or via a contracted supplier. Preferred Indiana CGM products do not require prior authorization. Codes marked with an asterisk in the Applicable Codes list are not managed for medical necessity review for Indiana; refer to the UnitedHealthcare Community Plan of Indiana prior authorization and notification list for the most current prior authorization requirements.

Non-preferred Indiana CGM products require prior authorization; preferred Indiana CGM products do not.
Codes with an asterisk in Applicable Codes are not managed for medical necessity review for Indiana — check the up-to-date prior authorization list.

Prior Authorization

Repair/Replacement Prior Authorization

Repair and replacement coverage and prior authorization for CGM components, insulin pumps, and supplies are governed by the separate Indiana Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements policy. Providers should follow that policy for claims related to repairs, replacements, and warranty-related services. Claims submitted under this policy that relate to repairs/replacements may be denied or redirected if they fall under the separate DME repairs/replacements policy.

Background and Scope

Background: Continuous glucose monitoring (CGM) systems continuously measure interstitial glucose and are used either short‑term (professional use for diagnostic purposes) or long‑term (personal use to guide ongoing diabetes management). Short‑term CGM (3–14 days) used by a healthcare provider for diagnostic evaluation is proven and medically necessary. Long‑term CGM includes personal rtCGM and intermittently scanned CGM; some long‑term systems include implantable sensors cleared for up to one year (for adults). This policy applies to Indiana Community Plan members and sets state‑specific coverage criteria (including referencing InterQual for external insulin pumps and non‑implantable CGM) and directs providers to Indiana program guidance for implantable devices and to ADA 2025 and relevant device definitions when documenting medical necessity.

Definitions and Device Terminology

inv-39: Adjunctive CGM — requires verification with blood glucose monitor

DefinitionAdjunctive CGM requires the user to verify CGM glucose levels or trends with a blood glucose monitor before making treatment decisions.

Source examplesDefinition referenced to CMS and ADA (2025) guidance within the policy definitions section.

Clinical implicationAdjunctive CGM cannot be used alone to make treatment changes without fingerstick confirmation.

inv-40: Hypoglycemia (Levels 2 and 3) — level definitions and clinical implications

Level 2 hypoglycemiaGlucose < 54 mg/dL (3.0 mmol/L); associated with increased risk for cognitive dysfunction and mortality.

Level 3 hypoglycemiaSevere event with altered mental and/or physical state requiring third‑party assistance; life‑threatening and requires emergent treatment.

Policy Revision History and Material Changes

2026-04-01policy_revisionLatest

Added language stating short-term CGM (3–14 days) used by a healthcare provider for diagnostic purposes is proven and medically necessary for managing individuals with diabetes.

2026-04-01policy_revision

Revised medical necessity criteria for non-implantable CGM: clarified intensive insulin therapy language and added initial long-term CGM coverage criteria for select non-intensive treatment plan patients with documented level 3 or recurrent level 2 hypoglycemia after treatment adjustments.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS024IN.14

Change TypeMaterial coverage revisions and coding updates

Effective DateApr 1, 2026

Next Review Date

Key ActionUse InterQual CP for medical necessity criteria and ensure prior authorization and documentation requirements are met for non-preferred Indiana CGM products.

SourceLink

On This Page

Long-term CGM is unproven and not medically necessary for managing individuals with diabetes on a non-intensive treatment plan (e.g., basal insulin and/or oral medications) for all other indications beyond the specific hypoglycemia criteria.

Policy states unproven/not medically necessary for other indications

Documentation requirement: Medical records must fully support medical necessity; coverage decisions are governed by federal, state, or contractual requirements and documentation does not guarantee coverage.N/A

Added in policy revision

ReauthorizationReauthorization (after initial period) may be for up to 12 months.

Applies toLong-term CGM (greater than 14 days) personal use devices.

inv-24: HbA1c — examples and thresholds cited in evidence or inclusion criteria

Example study inclusion HbA1c thresholdSeveral studies cited enrolled patients with HbA1c ≥ 7% (e.g., V-Go prospective study).

Evidence summariesSystematic reviews/meta-analyses (Ferreira 2024; Jancev 2024) report CGM use associated with reductions in mean HbA1c in non‑intensive T2D trials.

LimitationsTrials varied by device type, monitoring regimen, had small sample sizes and short follow-up, limiting generalizability.

inv-25: Short-term CGM duration (repeat) — diagnostic duration 3-14 days

Diagnostic duration windowShort-term CGM (repeat/diagnostic use) duration: 3–14 days per use.

Use caseWorn for a discrete period to assess glycemic patterns; may be clinic‑based (professional CGM) with blinded or visible data.

Policy noteAdded policy language (04/01/2026) clarifies short-term CGM diagnostic use is proven and medically necessary.

Refer to: Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for Indiana Only) for repair/replacement governance.
Repair/replacement requests may be denied or redirected if governed by the separate DME repairs/replacements policy.

Billing Rule

Applicable Codes and Prior Authorization

Certain HCPCS and other codes related to CGM, insulin delivery, and artificial pancreas systems are listed in the Applicable Codes section. Some codes may be excluded from medical necessity review in Indiana (marked with an asterisk in the Applicable Codes list). Providers must consult the Applicable Codes list and the UnitedHealthcare prior authorization resources to determine which codes require prior authorization or are subject to alternate review processes.

Applicable codes include (see Applicable Codes section): E0787, E2102, E2103, S1030, S1031, S1034, S1035, S1036, S1037.
Codes labeled with an asterisk in the policy’s Applicable Codes section are not managed for medical necessity review for Indiana at the policy effective date; verify current status in the UnitedHealthcare Indiana prior authorization list.

Documentation Required

Medical Record Documentation May Be Required

Clinical documentation may be requested to support medical necessity determinations. The member's medical record must fully support the requested service and may include history, physical examination findings, glucose monitoring data, HbA1c results, documentation of hypoglycemic events, prior attempts to optimize therapy, and any device download reports or clinician notes. Failure to provide required documentation may result in denial of the request.

Medical records documentation may be required to assess whether the member meets coverage criteria but does not guarantee coverage.
Documentation must be legible, maintained in the patient's medical record, and made available upon request.
Lack of documentation supporting medical necessity may lead to claim denial.

Documentation Required

Clinical Documentation and Guideline References

Clinical justification for CGM or insulin delivery devices should reference the member’s diabetes diagnosis (type 1, type 2, gestational, or other specified diabetes), complications, and relevant clinical guidelines (e.g., ADA Standards of Care 2025). Documentation should include device-specific data when available (CGM downloads, time in range, episodes of level 2/3 hypoglycemia), prior diabetes education and self-management efforts, and attempts to optimize medications or treatment plans where applicable.

Reference diabetes type and complications and cite ADA Standards of Care (2025) when applicable.
Provide CGM device data (time in range, TBR/TAR, downloads) and documentation of hypoglycemic events if applicable.
Document prior education, self-management, and attempts to adjust medications or the treatment plan.

Note

InterQual Criteria Requirement

InterQual CP criteria must be used for medical necessity clinical coverage determinations for insulin pumps and non-implantable CGM (initial and continuation). Providers should reference the InterQual® CP: Durable Medical Equipment, Continuous Glucose Monitors, Insulin Pumps, and Automated Insulin Delivery Technology criteria when submitting prior authorization requests. A link to the InterQual criteria is provided in the policy.

Use InterQual® CP criteria for insulin pumps and non-implantable CGM medical necessity reviews.
Refer to the InterQual CP: Durable Medical Equipment, Continuous Glucose Monitors, Insulin Pumps, and Automated Insulin Delivery Technology for initial and continuation requests.

Step Therapy

Treatment Optimization Required Before Long-term CGM for Some Patients

For individuals on non-intensive diabetes treatment plans (e.g., basal insulin and/or oral agents), initial long-term CGM is considered medically necessary only for those with a history of a level 3 hypoglycemic event or recurrent (more than one) level 2 hypoglycemic events that persist despite multiple attempts to adjust medications and/or modify the diabetes treatment plan. For all other indications in non-intensive therapy, long-term CGM is considered unproven and not medically necessary. Document attempts to optimize therapy (medication adjustments, education) prior to approval for long-term CGM in this population.

Initial long-term CGM for non-intensive regimen patients is medically necessary only with history of level 3 hypoglycemia or recurrent level 2 hypoglycemia that persists despite >1 attempts to adjust medications and/or modify treatment.
Long-term CGM is not medically necessary for non-intensive regimen patients for other indications.
Providers must document attempts to adjust medications and/or provide education prior to approval for long-term CGM in select non-intensive patients.

Clinical relevanceLevels inform eligibility and clinical decisions for long‑term CGM in select non‑intensive regimen patients per policy hypoglycemia criteria.

inv-41: isCGM — intermittently scanned (flash) CGM description

DefinitionIntermittently scanned (flash) CGM (isCGM) measures glucose continuously but requires scanning with a reader to visualize and store values.

Device componentsTypically two components: combined sensor/transmitter and a separate reader; available with or without alarms.

Use caseDesigned for long‑term personal use where the user scans to view data rather than continuous real‑time display.

inv-42: Non-Adjunctive CGM — can be used for treatment decisions without confirmatory fingerstick

DefinitionNon‑Adjunctive CGM can be used to make treatment decisions without confirmatory fingerstick blood glucose testing.

Regulatory notePolicy distinguishes non‑adjunctive devices from adjunctive devices per CMS and ADA definitions used in the document.

Clinical implicationAllows users to adjust insulin or other therapies based on CGM readings alone when device is non‑adjunctive.

inv-44: Real-Time CGM (rtCGM) — sensor, transmitter, and receiver providing real-time readings and alerts

ComponentsReal‑time CGM (rtCGM) devices have three components: sensor (subcutaneous), transmitter, and a handheld receiver and/or smartphone that displays glucose readings in real time.

FunctionalityMeasure and display glucose continuously with audible alerts when glucose is out of range; some systems require user calibration.

Use caseDesigned for long‑term personal management and allow users to take immediate action based on displayed data.

inv-44: CGM definition — continuous monitoring device components and available system durations

Core definitionContinuous glucose monitors (CGM) continuously monitor and record interstitial glucose levels and consist of three components: sensor, transmitter, and receiver.

System typesAvailable as short‑term professional/diagnostic devices (generally 7–14 days) and long‑term personal devices (rtCGM or isCGM); sensors may be disposable or implantable.

Implantable durationSome implantable sensors are cleared for extended durations (policy notes devices cleared for up to 1 year).

inv-45: Insulin pump — external and patch pump descriptions and capabilities

External pumpStandard external insulin pumps use tubing and an infusion set delivering basal and bolus insulin; programmable for basal rates and bolus dosing.

Patch pumpPatch pumps (e.g., OmniPod) combine an insulin reservoir adhered to the skin with a wireless controller to manage dosing without tubing.

Nonprogrammable transdermal devicesSome patch or transdermal devices (e.g., V‑Go) deliver preset basal and on‑demand bolus transdermally but lack programmability.

inv-46: CGM device duration note — short-term (3-14 day) and long-term (including implantable up to 1 year) definitions

Short-term definitionShort‑term (professional/diagnostic) CGM: generally 3–14 days worn for discrete diagnostic assessment.

Long-term definitionLong‑term personal CGM includes rtCGM and isCGM systems intended for ongoing use beyond 14 days; sensors may be disposable or implantable.

Implantable optionImplantable sensors are available and some systems are cleared for durations up to 1 year (e.g., Eversense 365 referenced elsewhere in policy).

inv-47: Insulin delivery systems — external pumps and hybrid closed-loop systems; no FDA-approved implantable insulin pumps.

External and hybrid systemsInsulin delivery systems include external insulin pumps (tubing plus infusion set) and automated/hybrid closed‑loop systems that integrate CGM and pump functions.

Implantable pumpsNo implantable insulin pumps have received FDA approval at this time; available only in clinical trial settings per policy.

ExamplesPolicy lists examples of pump models (e.g., Omnipod 5, Tandem t:slim X2 with Control‑IQ, Medtronic MiniMed systems).

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

2026-04-01documentation_requirement_added

Added requirements clarifying that medical records documentation may be required to assess clinical criteria and must fully support medical necessity (including history, exam, and pertinent diagnostic results).