CurrentUnitedHealthcarePolicy N/A

Continuous glucose monitors, sensors and transmitters

Defines medical necessity and prior authorization criteria for coverage of continuous glucose monitors (CGMs), sensors and transmitters for UnitedHealthcare members, including brand-specific guidance and a State of Illinois section; affects prescribers and pharmacy/benefit administrators.

Policy Summary

PayerUnitedHealthcare

PolicyContinuous glucose monitors, sensors and transmitters

Policy CodePolicy N/A

Change TypeMaterial updates — added brands and hypoglycemia criteria

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis, training, adherence and either intensive insulin use or specified hypoglycemia criteria.

SourceLink

POLICY UPDATE CHANGES

Added MiniMed Instinct to program.

Added Simplera to program and added definitions to hypoglycemia criteria; added section for State of Illinois.

Removed requirement for inadequate glycemic control and added criteria for hypoglycemia.

Added Guardian 4 to criteria and updated diabetes mandate language.

12 monthsauthorization period for most initial and reauthorizations

4+/dayrequired frequency of self-monitoring of blood glucose for certain initial approvals

<54 mg/dLhypoglycemia definition used as approval criterion

State-specificstate-specific rules

Coverage Criteria for Continuous Glucose Monitors

Initial Therapy (specified brands)

Covered when ALL of the following are met for Guardian Connect/3/4, MiniMed Instinct, Simplera and Simplera Sync:

Initial Authorization - Brand-specific: Patient has a diagnosis of diabetes; provider documents the patient is motivated and knowledgeable about use of continuous glucose monitoring; patient is adherent to diabetic treatment plan; patient participates in ongoing education and support; patient regularly monitors blood glucose 4 or more times per day; and authorization will be issued for 12 months.

Insulin therapy or hypoglycemia criteria (one required): (1) Patient is on an intensive insulin regimen (3 or more insulin injections per day or uses continuous subcutaneous insulin infusion pump) OR (2) patient has a history of a level 3 hypoglycemic event (glucose <54 mg/dL (3.0 mmol/L)) requiring third-party assistance OR (3) patient has a history of more than one level 2 hypoglycemia event (glucose <54 mg/dL (3.0 mmol/L)) that persist despite multiple attempts to adjust medications or modify the diabetes treatment plan.<54 mg/dL (3.0 mmol/L) for level 2/3 events

Limitation on preferred devices (one required): (1) Patient has a documented physical or mental limitation that makes utilization of Dexcom G6 or G7 unsafe, inaccurate, or not feasible (e.g., manual dexterity limitation) OR (2) patient has a documented physical or mental limitation that makes utilization of Freestyle Libre 2, Libre 2 Plus, Libre 3 or Libre 3 Plus unsafe, inaccurate, or not feasible (e.g., manual dexterity limitation).

Document the limitation

Initial Therapy (other CGMs)

Covered when ALL of the following are met for all other continuous glucose monitors:

Initial Authorization - Other CGMs: Patient has a diagnosis of diabetes; patient is motivated and knowledgeable about use of continuous glucose monitoring; patient is adherent to diabetic treatment plan; patient participates in ongoing education and support; patient regularly monitors blood glucose 4 or more times per day; and authorization will be issued for 12 months.

Reauthorization / Continuation Therapy

Covered when ALL of the following are met for continuation of therapy:

Reauthorization: Documentation of positive clinical response.

Authorization issued for 12 months; state mandates and member benefit plans may affect coverage

Initial Therapy (State of Illinois)

Illinois: Covered when ALL of the following are met:

Illinois Initial Authorization: Patient has a diagnosis of diabetes; provider attests the patient or caregiver has been provided sufficient training in using the continuous glucose monitor; patient uses insulin for treatment OR has a history of hypoglycemia as documented by either recurrent hypoglycemic events with altered mental or physical state despite treatment adjustments OR at least one hypoglycemia event requiring third-party assistance; and patient has had an in-person or telehealth visit to evaluate diabetes control within the past 6 months.

Authorization will be issued indefinitely

Coverage is not provided for indications that are unproven per medical benefit drug policy. UnitedHealthcare may also employ program-specific automated approval and re-approval processes that vary by therapeutic class; these processes do not change the exclusion for unproven indications.

There is no separate, explicit list of items designated as "not medically necessary" beyond the policy statement that coverage is not provided for indications unproven per medical benefit drug policy. Additional program-level rules (including automated approvals or supply limits) may apply but do not create a distinct NMN list in this policy.

Coding and Key Clinical Thresholds

No explicit CPT/HCPCS/NDC codes listedmixed

No codes listed

Hypoglycemia threshold

Hypoglycemia threshold<54 mg/dL (3.0 mmol/L)

Numeric equivalent3.0 mmol/L

Use in criteriaDefines both level 3 events requiring assistance and level 2 events used when recurrent despite treatment adjustments.

Self-monitoring frequency

Required self-monitoring frequency≥ 4 times per day

Role in authorizationPatient must regularly monitor blood glucose ≥4 times/day as part of initial authorization criteria.

Authorization periodAuthorization will be issued for 12 months when criteria met.

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization required — Initial approvals are issued for 12 months. Reauthorizations require documentation of ongoing need and adherence to the plan of care; supply limits may apply.

Initial authorizations issued for 12 months
Reauthorizations require documentation of ongoing need and adherence
Supply limits may be in place

Note

Coverage Specifics for Certain Brands

Coverage is provided for Guardian Connect, Guardian 3, Guardian 4, MiniMed Instinct, Simplera and Simplera Sync when Dexcom or Freestyle Libre monitors are not appropriate for the patient.

Applies when Dexcom or Freestyle Libre monitors are unsafe, inaccurate, or not feasible due to physical or mental limitations (e.g., manual dexterity)
Must document limitation

Documentation Required

Provider Documentation Requirements

Provider must document diagnosis of diabetes; that the patient or caregiver received sufficient training in use of the continuous glucose monitor; that the patient is motivated/knowledgeable about CGM use and is adherent to the diabetes treatment plan where required. Provider should also document specific clinical reasons why Dexcom G6/G7 or Freestyle Libre 2/3 series are not appropriate when claiming coverage for Guardian/MiniMed/Simplera products (e.g., history of level 2/3 hypoglycemia, physical or mental limitations).

Document diagnosis of diabetes
Document that patient/caregiver received sufficient training
Document patient is motivated and knowledgeable about CGM use
Document adherence to diabetic treatment plan when required
If applicable, document history of level 3 hypoglycemia (glucose <54 mg/dL) or recurrent level 2 hypoglycemia despite treatment adjustments
If applicable, document specific physical/mental limitations making Dexcom or Freestyle Libre systems unsafe or infeasible

Note

Automated Approval and Re-approval Processes

Use of automated approval and re-approval processes varies by program; UnitedHealthcare may approve initial and re-authorization based solely on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic. Coverage is not provided for indications unproven per the medical benefit drug policy.

Automated approvals may occur based on claims/medication history, diagnosis codes, and claim logic
Processes vary by program and therapeutic class
Coverage not provided for unproven indications per medical benefit drug policy

Background

Continuous glucose monitors provide glucose monitoring beyond standard blood glucose meters and are indicated for patients with diabetes who require enhanced glucose surveillance. The policy specifies device- and program-level criteria for coverage, and allows alternative devices when preferred options are unsafe, inaccurate, or not feasible for the individual patient.

Definitions

Level 3 hypoglycemic event

DefinitionGlucose <54 mg/dL (3.0 mmol/L) characterized by altered mental and/or physical state requiring third-party assistance.

Clinical implicationQualifies as level 3 hypoglycemia for meeting CGM hypoglycemia criteria in initial authorization.

DocumentationHistory of such an event must be documented to satisfy hypoglycemia-based criteria.

Level 2 hypoglycemia

DefinitionGlucose <54 mg/dL (3.0 mmol/L) events used to define level 2 hypoglycemia in this policy.

Use in criteriaMore than one level 2 event that persists despite multiple attempts to adjust medications or modify the diabetes treatment plan can meet hypoglycemia criteria for coverage.

Relation to level 3Level 2 shares the same numeric glucose threshold but is distinguished by recurrence despite treatment adjustment rather than requirement for third-party assistance.

Revision History and Policy Changes

2026-03-01material_revisionLatest

Added MiniMed Instinct and Simplera to the program; incorporated hypoglycemia definitions and removed the inadequate glycemic control requirement; added a State of Illinois section and updated mandate/state language and device listings.

2025-12-01addition

Added MiniMed Instinct to the program.

2025-09-01addition_and_definition_update

Added Simplera to the program and added definitions to hypoglycemia criteria; added section for State of Illinois.

2024-07-01addition_and_language_update

Added Guardian 4 to criteria and updated diabetes mandate language.

2022-02-01criteria_expansion

Added criteria for all continuous glucose monitors (program-wide criteria update).

Policy Summary

PayerUnitedHealthcare

PolicyContinuous glucose monitors, sensors and transmitters

Policy CodePolicy N/A

Change TypeMaterial updates — added brands and hypoglycemia criteria

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis, training, adherence and either intensive insulin use or specified hypoglycemia criteria.

SourceLink

On This Page

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Coverage Criteria for Continuous Glucose Monitors

Initial Therapy (specified brands)

Covered when ALL of the following are met for Guardian Connect/3/4, MiniMed Instinct, Simplera and Simplera Sync:

Document the limitation

Initial Therapy (other CGMs)

Covered when ALL of the following are met for all other continuous glucose monitors:

Reauthorization / Continuation Therapy

Covered when ALL of the following are met for continuation of therapy:

Reauthorization: Documentation of positive clinical response.

Authorization issued for 12 months; state mandates and member benefit plans may affect coverage

Initial Therapy (State of Illinois)

Illinois: Covered when ALL of the following are met:

Authorization will be issued indefinitely

Coding and Key Clinical Thresholds

No explicit CPT/HCPCS/NDC codes listedmixed

No codes listed

Hypoglycemia threshold

Hypoglycemia threshold<54 mg/dL (3.0 mmol/L)

Numeric equivalent3.0 mmol/L

Use in criteriaDefines both level 3 events requiring assistance and level 2 events used when recurrent despite treatment adjustments.

Self-monitoring frequency

Required self-monitoring frequency≥ 4 times per day

Role in authorizationPatient must regularly monitor blood glucose ≥4 times/day as part of initial authorization criteria.

Authorization periodAuthorization will be issued for 12 months when criteria met.

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization required — Initial approvals are issued for 12 months. Reauthorizations require documentation of ongoing need and adherence to the plan of care; supply limits may apply.

Initial authorizations issued for 12 months
Reauthorizations require documentation of ongoing need and adherence
Supply limits may be in place

Note

Coverage Specifics for Certain Brands

Coverage is provided for Guardian Connect, Guardian 3, Guardian 4, MiniMed Instinct, Simplera and Simplera Sync when Dexcom or Freestyle Libre monitors are not appropriate for the patient.

Applies when Dexcom or Freestyle Libre monitors are unsafe, inaccurate, or not feasible due to physical or mental limitations (e.g., manual dexterity)
Must document limitation

Documentation Required

Provider Documentation Requirements

Document diagnosis of diabetes
Document that patient/caregiver received sufficient training
Document patient is motivated and knowledgeable about CGM use
Document adherence to diabetic treatment plan when required
If applicable, document history of level 3 hypoglycemia (glucose <54 mg/dL) or recurrent level 2 hypoglycemia despite treatment adjustments
If applicable, document specific physical/mental limitations making Dexcom or Freestyle Libre systems unsafe or infeasible

Note

Automated Approval and Re-approval Processes

Automated approvals may occur based on claims/medication history, diagnosis codes, and claim logic
Processes vary by program and therapeutic class
Coverage not provided for unproven indications per medical benefit drug policy

Background

Definitions

Level 3 hypoglycemic event

DefinitionGlucose <54 mg/dL (3.0 mmol/L) characterized by altered mental and/or physical state requiring third-party assistance.

Clinical implicationQualifies as level 3 hypoglycemia for meeting CGM hypoglycemia criteria in initial authorization.

DocumentationHistory of such an event must be documented to satisfy hypoglycemia-based criteria.

Level 2 hypoglycemia

DefinitionGlucose <54 mg/dL (3.0 mmol/L) events used to define level 2 hypoglycemia in this policy.

Use in criteriaMore than one level 2 event that persists despite multiple attempts to adjust medications or modify the diabetes treatment plan can meet hypoglycemia criteria for coverage.

Relation to level 3Level 2 shares the same numeric glucose threshold but is distinguished by recurrence despite treatment adjustment rather than requirement for third-party assistance.

Revision History and Policy Changes

2026-03-01material_revisionLatest

2025-12-01addition

Added MiniMed Instinct to the program.

2025-09-01addition_and_definition_update

Added Simplera to the program and added definitions to hypoglycemia criteria; added section for State of Illinois.

2024-07-01addition_and_language_update

Added Guardian 4 to criteria and updated diabetes mandate language.

2022-02-01criteria_expansion

Added criteria for all continuous glucose monitors (program-wide criteria update).

OpenPayer

Continuous glucose monitors, sensors and transmitters

Coverage Criteria for Continuous Glucose Monitors

Coding and Key Clinical Thresholds

Provider Actions and Prior Authorization

Background

Definitions

Revision History and Policy Changes

OpenPayer

Continuous glucose monitors, sensors and transmitters

Coverage Criteria for Continuous Glucose Monitors

Coding and Key Clinical Thresholds

Provider Actions and Prior Authorization

Background

Definitions

Revision History and Policy Changes