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    OpenPayerPolicy UpdatesEndocrinologyUnitedHealthcare CGM Prior Auth Policy Update | Op…
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    CurrentUnitedHealthcarePolicy 2025 P 2170-12

    Prior Authorization/Medical Necessity — Continuous glucose monitors, sensors and transmitters

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    Prior authorization and medical necessity criteria for coverage of continuous glucose monitoring (CGM) devices and transmitters for UnitedHealthcare members; includes general book-of-business criteria and a state-specific section for Illinois.

    Policy Summary
    PayerUnitedHealthcare
    PolicyPrior Authorization/Medical Necessity — Continuous glucose monitors, sensors and transmitters
    Policy CodePolicy 2025 P 2170-12
    Change TypeMaterial clinical and program updates (device additions, criteria revisions)
    Effective DateMar 1, 2026
    Next Review DateN/A
    Key ActionObtain prior authorization; initial approvals for most CGMs are for 12 months and reauthorization requires documentation of positive clinical response.
    SourceLink
    POLICY UPDATE CHANGES

    Added MiniMed Instinct to program.

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

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

    Added Guardian 4 to criteria.

    Effective date set to 3/1/2026 and P&T approvals updated through 12/2025.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    12 monthsauthorization duration
    4x/daySMBG frequency
    Level 3: <54hypoglycemia threshold
    2025 P 2170-12program number
    Illinoisstate section

    Coverage Criteria for Continuous Glucose Monitors

    Initial Therapy - Specific device list

    Approved for initial therapy based on ALL of the following:

    Initial Authorization (Guardian Connect/3/4, MiniMed Instinct, Simplera*, Simplera Sync): a) Diagnosis of diabetes; b) Patient is motivated and knowledgeable about use of continuous glucose monitoring AND is adherent to diabetic treatment plan AND participates in ongoing education and support; c) One of: (1) intensive insulin regimen (3 or more insulin injections per day or uses continuous subcutaneous insulin infusion pump) OR (2) hypoglycemia history defined as either a level 3 hypoglycemic event (glucose <54 mg/dL) requiring third-party assistance OR more than one level 2 hypoglycemia event (glucose <54 mg/dL) that persist despite multiple attempts to adjust medications or modify diabetes treatment plan; d) Patient regularly monitors blood glucose 4 or more times per day; e) One of: (1) patient has a documented physical or mental limitation that makes utilization of Dexcom G6 or G7 unsafe, inaccurate, or not feasible 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

    Initial Therapy - All other CGMs

    Approved for initial therapy based on ALL of the following:

    Initial Authorization (All other CGMs): a) Diagnosis of diabetes; b) Patient is motivated and knowledgeable about use of continuous glucose monitoring AND is adherent to diabetic treatment plan AND participates in ongoing education and support; c) One of: (1) intensive insulin regimen (3 or more insulin injections per day or uses continuous subcutaneous insulin infusion pump) OR (2) hypoglycemia history defined as either a level 3 hypoglycemic event (glucose <54 mg/dL) requiring third-party assistance OR more than one level 2 hypoglycemia event (glucose <54 mg/dL) that persist despite multiple attempts to adjust medications or modify diabetes treatment plan; d) Patient regularly monitors blood glucose 4 or more times per day

    Reauthorization / Continuation

    Approved for continuation when the following is met:

    Reauthorization: Documentation of positive clinical response

    State of Illinois - Initial Therapy

    Illinois: Approved for initial therapy based on ALL of the following:

    Illinois Initial Authorization: a) Diagnosis of diabetes; b) Provider attests the patient or caregiver has been provided sufficient training in using the continuous glucose monitor; c) One of: (1) patient uses insulin for treatment OR (2) history of hypoglycemia as documented by either recurrent hypoglycemic events characterized by altered mental or physical state despite multiple attempts to adjust medications or modify treatment plan OR at least one hypoglycemia event characterized by altered mental or physical state requiring third-party assistance; d) Patient has had an in-person or telehealth visit to evaluate diabetes control within the past 6 months

    Coverage is not provided for indications deemed unproven per the medical benefit drug policy. UnitedHealthcare may decline authorization when the requested use does not meet evidence-based indications outlined in that policy.

    Indications that are considered unproven per the medical benefit drug policy are not covered. This exclusion applies regardless of prior claim history or submitted documentation when the use falls outside of the policy’s defined, evidence-based indications.

    Coding and Monitoring Requirements

    Covered CPT Codesmixed
    No codes listed
    Self-monitored blood glucose frequency
    Required frequency>= 4 times per day
    Context in initial authorizationPatient regularly monitors blood glucose 4 or more times per day (required for initial therapy)
    Applies toAll CGM initial authorization pathways (specific-device and all-other CGMs)

    Provider Actions, Prior Authorization, and Exceptions

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for continuous glucose monitors (CGMs). Initial approvals are generally issued for 12 months; reauthorization also requires documentation of clinical benefit and is typically approved for 12 months. UnitedHealthcare may use automated approval/re-approval processes based on claims history, diagnosis codes, and claim logic. Supply limits may apply. Coverage is not provided for indications deemed unproven per the medical benefit drug policy.

    • Initial authorization: typically 12 months
    • Reauthorization: documentation of positive clinical response; typically 12 months
    • Automated approvals may be used based on claims/diagnosis history
    • Supply limits may apply
    • Unproven indications are not covered
    Note

    Preferred Device Logic and Exceptions

    Coverage is provided for specified devices (Guardian Connect, Guardian 3, Guardian 4, MiniMed Instinct, Simplera and Simplera Sync) when Dexcom or FreeStyle Libre devices are not appropriate for the patient. Exceptions may be granted when the patient has physical or mental limitations that make use of Dexcom G6/G7 or FreeStyle Libre 2/2 Plus/3/3 Plus unsafe, inaccurate, or otherwise not feasible. Document the limitation and rationale for device exception.

    Definitions Relevant to Criteria

    Level 3 hypoglycemia
    DefinitionGlucose <54 mg/dL (3.0 mmol/L) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia
    Relevance to coverageCounts as Level 3 hypoglycemia for meeting hypoglycemia criteria in initial authorization
    Evidence locationDefined in policy hypoglycemia criteria
    Level 2 hypoglycemia
    DefinitionHypoglycemia events with glucose <54 mg/dL (3.0 mmol/L) referenced as recurrent events that persist despite multiple attempts to adjust medications or modify the diabetes treatment plan
    Use in criteria>1 Level 2 events despite treatment changes qualifies under hypoglycemia criterion for initial authorization

    Background

    Continuous glucose monitors (CGMs) provide ongoing interstitial glucose measurement for patients who require monitoring beyond standard blood glucose meters. This policy defines coverage criteria for CGM devices and transmitters, including specific criteria for named devices (Guardian Connect/3/4, MiniMed Instinct, Simplera products) and general criteria for other CGMs. Key requirements across the policy include documentation of a diabetes diagnosis, patient knowledge/motivation and adherence to the diabetes treatment plan with participation in ongoing education/support, evidence of either an intensive insulin regimen (≥3 injections per day or continuous subcutaneous insulin infusion) or a qualifying hypoglycemia history (for example, a <54 mg/dL event requiring assistance or recurrent level 2 events despite treatment changes), and routine self-monitoring of blood glucose ≥4 times per day. Prior authorization is required; initial approvals for most CGMs are issued for 12 months (book-of-business), reauthorization requires documentation of a positive clinical response, and Illinois-specific approvals are issued indefinitely when the state criteria are met.

    Policy Summary
    PayerUnitedHealthcare
    PolicyPrior Authorization/Medical Necessity — Continuous glucose monitors, sensors and transmitters
    Policy CodePolicy 2025 P 2170-12
    Change TypeMaterial clinical and program updates (device additions, criteria revisions)
    Effective DateMar 1, 2026
    Next Review DateN/A
    Key ActionObtain prior authorization; initial approvals for most CGMs are for 12 months and reauthorization requires documentation of positive clinical response.
    SourceLink
    On This Page
    Coverage Criteria for Continuous Glucose MonitorsCoding and Monitoring RequirementsProvider Actions, Prior Authorization, and ExceptionsDefinitions Relevant to CriteriaBackground
    • Preferred devices: Dexcom and FreeStyle Libre are preferred when appropriate
    • Covered alternatives when preferred devices are not appropriate: Guardian Connect/3/4, MiniMed Instinct, Simplera products
    • Document patient-specific limitation (e.g., manual dexterity) that precludes use of preferred device
    Documentation Required

    Provider Documentation Requirements

    Provider must document the diagnosis of diabetes. For initial authorization, providers must also document that the patient is motivated and knowledgeable about CGM use, is adherent to the diabetic treatment plan when required, and has had an in-person or telehealth diabetes visit within the past 6 months when applicable. For device exceptions, document the specific physical or mental limitation making the preferred device unsafe or infeasible. For reauthorization, document a positive clinical response. In certain states (FL, ME, TN, TX), provider attestation and documentation that alternatives are clinically contraindicated or would worsen the patient’s condition may be required.

    • Documented diagnosis of diabetes (required)
    • Initial authorization: documentation that patient is motivated/knowledgeable about CGM use
    • Document adherence to diabetic treatment plan when applicable
    • Document a diabetes evaluation (in-person or telehealth) within past 6 months when required
    • Document specific limitations if preferring non‑Dexcom/Libre device
    • Reauthorization: documentation of positive clinical response
    • State-specific requirements (FL, ME, TN, TX): provider attestation and clinical justification
    Note

    Provider Actions and Operational Notes

    When prescribing or requesting authorization, providers should confirm member-specific benefit plan coverage and any applicable state mandates. Be aware that supply limits may be enforced and automated approvals may apply; ensure clinical documentation supports medical necessity to avoid denials.

    • Verify member benefit and state mandates
    • Anticipate supply limits and document quantity needs
    • Provide sufficient clinical documentation to support medical necessity to reduce denial risk
    Policy text locationSpecified within initial authorization hypoglycemia rules