CurrentUnitedHealthcarePolicy N/A

Continuous Glucose Monitors, Sensors, and Transmitters — Prior Authorization

Prior authorization and reauthorization requirements for continuous glucose monitoring (CGM) devices for patients with diabetes under UnitedHealthcare Pharmacy Clinical Pharmacy Programs. Affects providers requesting CGM coverage through UnitedHealthcare.

Policy Summary

PayerUnitedHealthcare

PolicyContinuous Glucose Monitors, Sensors, and Transmitters — Prior Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 15, 2026

Next Review DateNov 1, 2025

Key ActionObtain prior authorization with documentation of diabetes diagnosis and required supporting clinical documentation (motivation/knowledge, adherence, education for initial; positive clinical response for reauthorization).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moauthorization duration

Diabetesinitial requirement

Positive responsereauthorization

Possibleautomated approvals

Nationalgeographic scope

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Coverage Criteria for Continuous Glucose Monitoring

Initial Therapy

Covered when ALL of the following are met for initial therapy

Initial Authorization: (a) Diagnosis of diabetesauthorization = 12 months

AND: (b) All of the following:

Patient requirements

(1): Patient is motivated and knowledgeable about use of continuous glucose monitoring
(2): Patient is adherent to diabetic treatment plan
(3): Patient participates in ongoing education and support

Continuation Therapy / Reauthorization

Covered when the following is met for continuation of therapy

Reauthorization: Documentation of positive clinical responseauthorization = 12 months

Supply limits and medical necessity rules may apply to requests for continuous glucose monitors, sensors, and transmitters. UnitedHealthcare reserves the right to apply program-specific limits or medical necessity determinations when adjudicating initial authorizations and reauthorizations.

UnitedHealthcare may also approve initial or reauthorization requests based solely on previous claim/medication history, diagnosis codes (ICD-10), and/or claim logic; the use of automated approval and re-approval processes varies by program or therapeutic class. Historical change notes document prior modifications to the criteria and program rules dating from 2016 through 2025, including revisions to authorization timelines and eligibility requirements.

ICD-10 and Claims Logic

ICD-10 / claims logicICD-10

No codes listed

Provider Requirements and Authorization Process

Prior Authorization

Prior authorization required for CGM (initial = diagnosis + patient factors)

Prior authorization is required. Initial authorization requires a diagnosis of diabetes and that the patient is motivated and knowledgeable about CGM use, adherent to the diabetes treatment plan, and participates in ongoing education/support. Authorizations are issued for 12 months.

Billing Rule

Supply limits and medical necessity may apply; automated processes used

Supply limits and medical necessity rules may apply to approvals. The program may use automated approval or re-approval processes based on claims, medication history, diagnosis codes (ICD-10), and/or claim logic.

Supply limits may be in place.
Medical necessity may be applied.

Background

Continuous glucose monitors (CGMs) are devices used by patients with diabetes to provide ongoing, frequent glucose readings that support diabetes management and clinical decision-making. The program references multiple change-control entries that reflect evolving evidence and program updates over time, including additions and removals of specific eligibility requirements and periodic annual reviews.

Definitions

Continuous glucose monitors, sensors, and transmitters — definition

DefinitionAll brands of continuous glucose monitoring systems (continuous glucose monitors, sensors, and transmitters) used to provide ongoing glucose readings for patients with diabetes.

Program and scopeIncluded in UnitedHealthcare Pharmacy Clinical Pharmacy Programs prior authorization/notification (Program Number 2025 P 1206-11); applicable to all brands.

Effective dateEffective date of policy: 02/15/2026.

Authorization durationAuthorizations are issued for 12 months for initial approval.

Covered indicationCovered for patients with a diagnosis of diabetes when other initial criteria are met (see coverage criteria).

Policy Summary

PayerUnitedHealthcare

PolicyContinuous Glucose Monitors, Sensors, and Transmitters — Prior Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 15, 2026

Next Review DateNov 1, 2025

SourceLink

On This Page

Approvals may be based solely on previous claim/medication history, diagnosis codes, and/or claim logic.

Documentation Required

Documentation required for initial authorization and reauthorization

Initial requests must document a diagnosis of diabetes and that the patient is motivated and knowledgeable about use of continuous glucose monitoring, is adherent to the diabetes treatment plan, and participates in ongoing education/support. Reauthorization must document a positive clinical response. Authorizations are issued for 12 months.

Initial documentation: diagnosis of diabetes; patient motivated and knowledgeable; adherent to treatment plan; participates in ongoing education/support.
Reauthorization documentation: positive clinical response.
Authorization duration: 12 months.

Denial Risk

Denial risk if claims or diagnosis data are insufficient

Use of automated approval and re-approval processes varies by program and therapeutic class; approvals may be issued based solely on previous claim/medication history, diagnosis codes (ICD-10), and/or claim logic, which can trigger denial if those data are insufficient.

Approvals issued solely on claims/medication history or diagnosis codes may be denied if those data are incomplete or insufficient.