CurrentUnitedHealthcarePolicy 2025 P 2170-12

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

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.

12 monthsauthorization duration

4x/daySMBG frequency

Level 3: <54hypoglycemia threshold

2025 P 2170-12

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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.