CurrentUnitedHealthcarePolicy 1 = 2025 P 1206-11

Prior Authorization — Continuous Glucose Monitors, Sensors, and Transmitters

Prior authorization policy for coverage and renewal of continuous glucose monitors (all brands) for patients with diabetes under UnitedHealthcare Pharmacy Clinical Pharmacy Programs.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization — Continuous Glucose Monitors, Sensors, and Transmitters

Policy CodePolicy 1 = 2025 P 1206-11

Change TypeNo material changes

Effective Date2/15/2026

Next Review Date

Key ActionObtain prior authorization with documentation of diagnosis and required clinical criteria; approvals issued for 12 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moauthorization duration

All brandsapplies to

2016–2025P&T approvals

Coverage and Medical Necessity Criteria

Initial Authorization

Approved when ALL of the following are met

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization — Continuous Glucose Monitors, Sensors, and Transmitters

Policy CodePolicy 1 = 2025 P 1206-11

Change TypeNo material changes

Effective Date2/15/2026

Next Review Date

Key ActionObtain prior authorization with documentation of diagnosis and required clinical criteria; approvals issued for 12 months.

SourceLink

On This Page

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Provider Requirements and Authorization Process

Prior Authorization

Prior Authorization Required

Prior authorization is required for initial and continuing use of continuous glucose monitors, sensors, and transmitters. When criteria are met, initial and reauthorization approvals are issued for 12 months.

Prior authorization required for initial and continuation therapy; initial approval = 12 months when criteria met
Reauthorization approval = 12 months when documentation of positive clinical response is provided

Denial Risk

Supply Limits and Automated Approvals

Supply limits, medical necessity edits, and automated approval logic may affect claims. Automated approvals or re-authorizations can occur based on prior claim/medication history, diagnosis codes (ICD-10), and claim logic — processes vary by program and therapeutic class.

Supply limits may be in place
Medical necessity edits may apply
Automated approvals or re-approvals may be granted based on previous claims, medication history, diagnosis codes (ICD-10), and claim logic

Documentation Required

Required Documentation for Approval

Document the clinical information required for initial authorization and reauthorization. Ensure records submitted clearly demonstrate the criteria below.

Initial authorization: diagnosis of diabetes; evidence the patient is motivated and knowledgeable about CGM use; adherence to diabetic treatment plan; participation in ongoing education and support
Reauthorization: documentation of positive clinical response to therapy
Operational documentation: relevant ICD-10 diagnosis codes, prior claim/medication history if available, dates of education/support participation, notes on patient motivation and adherence

Denial Risk

Automated Approval and Denial Risk

Automated approval and denial risk vary by program; supply limits or medical necessity edits may still cause a claim denial even when previous approvals exist. Providers should verify member-specific rules and supply limits before submitting claims.

Automated approval/re-approval processes vary by program and therapeutic class
Supply limits or medical necessity edits may result in claim denial despite prior approvals
Verify member-specific benefit rules and supply limits prior to submission to reduce denial risk

Device Definitions

Continuous glucose monitors, sensors, and transmitters — definitions

Continuous glucose monitor (CGM)Device that provides continuous monitoring of glucose concentrations for patients requiring monitoring beyond what a standard blood glucose monitor provides.

SensorThe component that measures interstitial glucose levels and transmits readings to the CGM receiver or compatible display device.

TransmitterThe device that sends glucose data from the sensor to the receiver, display device, or compatible smart device for real-time or stored review.

Receiver/Display deviceA dedicated receiver or compatible smart device that displays glucose readings and trend information provided by the sensor/transmitter.

Clinical useUsed for patients with diabetes who require monitoring beyond what can be achieved with a standard blood glucose monitor, supporting ongoing glucose management and therapy decisions.

Background and Clinical Context

Continuous glucose monitoring systems—including sensors and transmitters—are used to provide ongoing measurement of glucose for people with diabetes who require monitoring beyond intermittent finger‑stick testing. This policy establishes coverage through prior authorization for these devices but also highlights that approvals may be determined by claims history, diagnosis codes, or automated rules in addition to the clinical documentation required by the criteria.