CurrentUnitedHealthcarePolicy CS024IN.14

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for Indiana Only) – Community Plan Medical Policy

UnitedHealthcare Community Plan Indiana medical policy describing coverage, medical necessity criteria, definitions, applicable codes, and evidence background for continuous glucose monitors (short-term, long-term, implantable, adjunctive/nonadjunctive, rtCGM/isCGM) and external insulin delivery devices (external insulin pumps, automated insulin delivery). Applies only to Indiana.

Policy Summary

PayerUnitedHealthcare

PolicyContinuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for Indiana Only) – Community Plan Medical Policy

Policy CodePolicy CS024IN.14

Change TypeMaterial revisions and code updates (04/01/2026)

Effective DateApr 1, 2026

Next Review Date

Key ActionFor initial and continuation requests, ensure InterQual CP criteria are met and submit legible medical record documentation that fully supports medical necessity; prior authorization is required for non-preferred Indiana CGM products.

SourceLink

POLICY UPDATE CHANGES

Added short-term CGM diagnostic coverage language (04/01/2026).

Revised long-term and intensive vs non-intensive CGM medical necessity criteria (04/01/2026).

Removed specific CPT/HCPCS codes from Applicable Codes section.

Added documentation requirements clarifying that documentation must support medical necessity.

Updated Supporting Information: Description of Services, Clinical Evidence, FDA, and References.

Coverage Summary

This UnitedHealthcare Community Plan policy (Policy Number CS024IN.14) applies only to Indiana and is effective April 1, 2026. It addresses continuous glucose monitors (CGMs) — including short-term (3–14 day professional), long-term (greater than 14 days), and implantable CGM sensors — and insulin delivery devices including external insulin pumps and automated insulin delivery systems. The Policy History records a material change on 04/01/2026 (added language that short-term CGM used by a healthcare provider for diagnostic purposes is proven and medically necessary and revised long-term CGM criteria).

Key coverage determinations summarized: Short-term CGM (3–14 days) used by a healthcare provider for diagnostic purposes is proven and medically necessary. For long-term (non-implantable) CGM, initial authorization is up to 6 months and reauthorization up to 12 months; initial long-term CGM for individuals on a non-intensive treatment plan is medically necessary only when there is a history of level 3 hypoglycemia or recurrent (more than one) level 2 hypoglycemic events that persist despite multiple (more than one) attempts to adjust medications or the treatment plan; otherwise long-term CGM for non-intensive therapy is considered unproven and not medically necessary. External continuous subcutaneous insulin infusion pumps are medically necessary when used according to FDA-labeled indications and InterQual clinical criteria (examples of populations include diabetes due to other causes requiring intensive insulin therapy, i.e., insulin-treated at least 3 times/day). Implantable insulin pumps are currently unproven/not medically necessary (only available in clinical trial settings). The policy also notes that implantable CGM criteria follow Indiana Health Coverage Programs guidance (Bulletin BT202520).

The policy clarifies that documentation supporting medical necessity may be required and that documentation does not guarantee coverage; benefit coverage is determined by federal, state, or contractual requirements and applicable law.

Key Thresholds

Short-term CGM wear duration3-14 days

Long-term CGM initial authorizationup to 6 months

Long-term CGM reauthorizationup to 12 months

Insulin-treated frequency for pump considerationat least 3 times/day

Recurrent level 2 hypoglycemia thresholdmore than one event

Multiple attempts to adjust medications/treatment planmore than one attempt

Medical Necessity Criteria

Insulin Delivery - External Insulin Pumps

External continuous subcutaneous insulin infusion pumps coverage logic and related device determinations.

Used according to FDA labeled indications, contraindications, warnings, and precautions

Refer to InterQual criteria link

Examples of populations where external pumps are medically necessary

Individuals with diabetes due to other causes who require intensive insulin therapy (insulin-treated at least 3 times a day) e.g., cystic fibrosis-related diabetes
Post-transplantation diabetes requiring intensive insulin therapy
Diabetes following pancreatic surgery requiring intensive insulin therapy

Applicable Codes

CPT / HCPCS / Other procedure codes (referential)mixed

0446T	Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training
0448T	Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation
95249	Ambulatory continuous glucose monitoring... patient-provided equipment, sensor placement, hook-up, calibration, patient training, and printout
95250	Ambulatory CGM... physician or qualified HCP provided equipment, placement, calibration, training, removal, and printout
95251	Ambulatory CGM analysis, interpretation and report
A4226	Supplies for maintenance of insulin infusion pump with dosage rate adjustment using therapeutic continuous glucose sensing, per week
A4238	Supply allowance for adjunctive, nonimplanted CGM, 1 month supply = 1 unit
A4239	Supply allowance for nonadjunctive, nonimplanted CGM, 1 month supply = 1 unit
A9274	External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories
A9276	Sensor; invasive, disposable, for use with interstitial CGM system, one unit = 1 day supply

1–10 of 22

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HCPCS codes not managed for medical necessity review (Indiana at policy effective date)HCPCS

0446T	See note - not managed for medical necessity review for Indiana
0448T	See note - not managed for medical necessity review for Indiana
95249	See note - not managed for medical necessity review for Indiana
95250	See note - not managed for medical necessity review for Indiana
95251	See note - not managed for medical necessity review for Indiana

ICD-10 Diagnosis Codes (examples listed)ICD-10

E11.00	Type 2 diabetes mellitus with hyperosmolarity without coma
E11.01	Type 2 diabetes mellitus with hyperosmolarity with coma
E11.10	Type 2 diabetes mellitus with ketoacidosis without coma
E11.11	Type 2 diabetes mellitus with ketoacidosis with coma
E11.21	Type 2 diabetes mellitus with diabetic nephropathy
E11.22	Type 2 diabetes mellitus with diabetic chronic kidney disease
E11.29	Type 2 diabetes mellitus with other diabetic kidney complication
E11.311	Type 2 diabetes with unspecified diabetic retinopathy with macular edema
E11.319	Type 2 diabetes with unspecified diabetic retinopathy without macular edema
E11.641	Type 2 diabetes with hypoglycemia with coma

1–10 of 15

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Removed/Deleted CPT/HCPCS codesmixed

0447T	Removed from Applicable Codes (document notes removal)
G0564	Removed from Applicable Codes (document notes removal)
G0565	Removed from Applicable Codes (document notes removal)

Provider Actions & Authorization

Prior Authorization

Prior authorization for non-preferred Indiana CGM products

Short-term and preferred Indiana continuous glucose monitoring (CGM) products do not require prior authorization. For non-preferred Indiana CGM products, submit a prior authorization request; the coverage criteria below must be met whether the request is submitted through UnitedHealthcare prior authorization or via a contracted supplier.

Preferred Indiana CGM products do not require prior authorization.
Non-preferred Indiana CGM products require prior authorization and must meet the policy's coverage criteria.

Prior Authorization

Refer to InterQual for detailed medical necessity criteria

Initial and continuation requests for non-implantable CGM intensive insulin therapy and external insulin pumps must meet InterQual clinical pathway (CP) criteria. When authorizing these services, cite the InterQual CP: Durable Medical Equipment, Continuous Glucose Monitors, Insulin Pumps, and Automated Insulin Delivery Technology.

Background & Evidence

Background/context: Diabetes management uses blood glucose monitoring (BGM), continuous glucose monitoring (CGM), and laboratory HbA1c testing to assess glycemic status; improved glycemic control reduces complications. CGM devices continuously monitor interstitial glucose and typically comprise a sensor, transmitter, and receiver; sensors may be disposable or implantable and some systems are short-term (clinic/professional) while others are for long-term personal use (rtCGM, isCGM).

Device types and regulatory status: External insulin pumps (standard tethered pumps and patch/pod systems) can provide basal and bolus insulin delivery; nonprogrammable transdermal devices (e.g., V-Go) and implantable insulin pumps have distinct evidence considerations (implantable pumps currently only in clinical trials). The policy references FDA device listings for pumps and CGMs and notes specific CGM models and that some implantable sensors (e.g., Eversense) have received FDA clearance for longer duration use.

Professional guidelines and evidence: The policy cites guidance and evidence from professional societies (ADA, AACE, Endocrine Society) and systematic reviews/meta-analyses (e.g., Ferreira 2024; Jancev 2024) showing CGM benefits for time-in-range and HbA1c reductions in type 2 diabetes with limitations (small trials, short follow-up). ECRI assessments and randomized trials (e.g., MOBILE) are summarized; noninvasive CGMs have no FDA-approved options at this time.

Coverage considerations and program guidance: The policy emphasizes use of InterQual clinical criteria for medical necessity determinations for non-implantable CGM intensive therapy and external insulin pumps, and refers to Indiana Health Coverage Programs Bulletin BT202520 for implantable glucose sensor criteria. It also notes preferred versus non-preferred Indiana CGM product handling (non-preferred require meeting coverage criteria and prior authorization).

Evidence / Source	Summary
Systematic reviews/meta-analyses
Ferreira et al. 2024; Jancev et al. 2024 show CGM benefits in type 2 diabetes for time in range and HbA1c reductions, with limitations of small sample sizes and short follow-up
ECRI assessment
ECRI 2025 update favorable for CGM replacing BGM in noninsulin therapies based on systematic review (previously inconclusive)
MOBILE Study (JAMA 2021)
Effect of CGM on glycemic control in patients with type 2 diabetes treated with basal insulin (Martens et al., MOBILE Study Group)
Systematic review (Diabetologia 2024)
Jancev et al. 2024 systematic review/meta-analysis: CGM (rtCGM or isCGM) associated with HbA1c reduction, increased time in range, decreased time above/below range; limitations include small sample sizes and short follow-up

Adjunctive CGM: An Adjunctive CGM requires verification of CGM glucose levels/trends with a blood glucose monitor prior to making treatment decisions.

Medicare Determinations

Name	Number	Type	Effective Date
{"text":"Glucose monitors (CMS Local Coverage Determination)","status":""},{"text":"L33822","status":""},{"text":"LCD","status":""},{"text":"","status":""}

Revision History

04/01/2026material_changeLatest

Policy History: Added language indicating short-term CGM (3-14 days) use by a healthcare provider for diagnostic purposes is proven and medically necessary; revised medical necessity clinical coverage criteria for non-implantable CGM including clarification that initial long-term CGM is medically necessary for non-intensive therapy when specific hypoglycemia history exists, otherwise long-term CGM is unproven and not medically necessary for non-intensive therapy; Updated medical records documentation language; Removed CPT/HCPCS codes 0447T, G0564, and G0565; Updated supporting information sections.

04/01/2026addedLatest

Added coverage rationale for Short-Term CGM (3-14 days): short-term CGM use by a healthcare provider for diagnostic purposes is proven and medically necessary for managing individuals with diabetes.

Policy Summary

PayerUnitedHealthcare

PolicyContinuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for Indiana Only) – Community Plan Medical Policy

Policy CodePolicy CS024IN.14

Change TypeMaterial revisions and code updates (04/01/2026)

Effective DateApr 1, 2026

Next Review Date

SourceLink

On This Page

Continuous Glucose Monitoring - Short-Term (3-14 days)

Short-term/professional CGM (3-14 days) used by a healthcare provider for diagnostic purposes.

Short-term continuous glucose monitoring (3-14 days) use by a healthcare provider for diagnostic purposes is proven and medically necessary for managing individuals with diabetes

Added 04/01/2026 policy revision

Long-Term CGM - Non-Intensive Diabetes Therapy (Initial Coverage)

Initial coverage criteria for long-term CGM in non-intensive diabetes therapy.

ALL of the following must be met: individual is on a non-intensive treatment plan (e.g., basal insulin and/or oral medications); history of a level 3 hypoglycemic event OR recurrent (more than one) level 2 hypoglycemic events that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan

Long-Term CGM - Non-Intensive Diabetes Therapy (Not Covered)

Not medically necessary branch for long-term CGM in non-intensive therapy.

Long-term CGM is unproven and not medically necessary for individuals on a non-intensive treatment plan (e.g., basal insulin and/or oral medications) for all other indications not meeting the above hypoglycemia/history criteria

Non-Implantable Continuous Glucose Monitoring Intensive Insulin Therapy

InterQual governs initial and continuation requests for non-implantable CGM intensive insulin therapy.

InterQual referral: Refer to InterQual CP: Durable Medical Equipment, Continuous Glucose Monitors, Insulin Pumps, and Automated Insulin Delivery Technology for medical necessity clinical coverage criteria for initial and continuation requests

Authorization decisions reference InterQual

Implantable Continuous Glucose Monitoring

Implantable sensor coverage references Indiana Health Coverage Programs guidance.

Implantable sensor reference: For medical necessity clinical coverage criteria for implantable glucose sensors (e.g., Eversense), refer to Indiana Health Coverage Programs Bulletin BT202520

Implantable sensor criteria reference external bulletin

Short-Term CGM (3-14 Days) Coverage Rationale (from 04/01/2026 revision)

Policy revision on 04/01/2026 added explicit short-term CGM coverage rationale.

Short-term continuous glucose monitoring (3-14 days) used by a healthcare provider for diagnostic purposes is proven and medically necessary for managing individuals with diabetes

Material change recorded 04/01/2026

Long-Term Non-Implantable CGM - Intensive vs Non-Intensive Therapy (policy revision summary)

Policy logic comparing intensive vs non-intensive therapy and resulting coverage statements (revision summary).

Intensive Insulin Therapy: Revised language indicates coverage for non-implantable CGM intensive insulin therapy follows InterQual criteria (details in InterQual)

Refer to InterQual for criteria

Non-Intensive Diabetes Therapy - Initial Long-Term CGM: Member is on a non-intensive treatment plan (e.g., basal insulin and/or oral medications) AND has history of a level 3 hypoglycemic event OR recurrent (more than one) level 2 hypoglycemic events that persist despite multiple (more than one) attempts to adjust medications/treatment plan; initial long-term CGM is medically necessary

Non-Intensive Diabetes Therapy - Not Covered: Long-term CGM is unproven and not medically necessary for non-intensive therapy for all indications not meeting the hypoglycemia/history criteria above

Medical Records Documentation Used for Reviews

Documentation that may be required to support medical necessity and coverage determinations.

Coverage determination note: Benefit coverage is determined by federal, state, or contractual requirements and applicable laws which may require coverage for a specific service

Documentation requirement: Medical records documentation may be required to assess whether the member meets clinical criteria for coverage but does not guarantee coverage

Medical necessity support: The patient’s medical record must contain documentation that fully supports the medical necessity for the requested services (includes relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures)

Documentation standards: Documentation supporting medical necessity should be legible, maintained in the patient’s medical record, and must be made available upon request

Documentation Required

Medical records documentation requirement

The patient's medical record must fully support medical necessity. Ensure documentation is complete, legible, and available upon request.

Include relevant medical history (diabetes type, treatment regimen, prior hypoglycemic events, prior attempts to adjust therapy).
Document physical examination findings relevant to diabetes management when applicable.
Provide results of pertinent diagnostic tests or procedures (e.g., glucose logs, A1c, continuous glucose monitoring reports, records of level 2 or level 3 hypoglycemic events).
Records must be legible and maintained in the patient's medical record.
Make documentation available upon request to support the authorization review.

Documentation Required

Support medical necessity with medical record documentation

To support medical necessity for device coverage or continued authorization, include the specific clinical elements below in the medical record.

Clear statement of the indication and treatment plan (e.g., intensive vs non-intensive insulin therapy).
Detailed history of hypoglycemia (level 2 or level 3 events) with dates and interventions.
Evidence of prior treatment adjustments or attempts (medication changes, education, monitoring) and their outcomes.
Relevant diagnostic results (A1c, glucose logs, prior CGM/SMBG data) and device usage data when applicable.
Documentation must be legible and accessible for review; absence of required documentation may delay or deny authorization.

Prior Authorization

Coverage determination subject to federal/state/contract rules

Benefit coverage is governed by applicable federal, state, and contractual requirements. When federal, state, or contract rules supersede policy, coverage determinations and prior authorization requirements will follow those rules.

Coverage may be required by federal/state/contractual law even if not otherwise covered by this policy.
Preauthorization requirements may vary if federal, state, or contractual requirements apply (e.g., specific device coverage mandates).

04/01/2026revisedLatest

Revised Non-Implantable CGM criteria: clarified intensive insulin therapy criteria reference InterQual and revised Non-Intensive Diabetes Therapy criteria — initial long-term CGM is medically necessary for individuals on non-intensive regimens with a history of a level 3 hypoglycemic event or recurrent (more than one) level 2 hypoglycemic events that persist despite multiple attempts to adjust therapy; long-term CGM is unproven and not medically necessary for other non-intensive indications.

04/01/2026updatedLatest

Added/clarified Medical Records Documentation Used for Reviews: benefit coverage is determined by federal, state, or contractual requirements; medical records may be required to assess clinical criteria but do not guarantee coverage; patient record must fully support medical necessity and include relevant history, exam, and diagnostic test results; documentation must be legible and available upon request.