A4226 — Supplies for maintenance of insulin infusion pump with dosage rate adjustment using therapeutic continuous glucose sensing, per week
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- "Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage"; refer to the protocol titled Medical Records Documentation Used for Reviews.
- For intensive insulin therapy indications: documentation that the individual is "insulin-treated at least 3 times a day" or is using an insulin pump (as applicable).
- For non-intensive therapy hypoglycemia indications: documentation of history of a level 3 hypoglycemic event OR recurrent (more than one) level 2 hypoglycemic events, and documentation that these events "persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan."
- For implantable CGM: documentation of age ≥ 18 and meeting one of the stated clinical criteria (intensive insulin therapy or qualifying hypoglycemia history and prior failed therapeutic adjustments).
Key Coverage Criteria
- External continuous subcutaneous insulin infusion pumps are proven and medically necessary in certain circumstances when used according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Durable Medical Equipment, Continuous Glucose Monitors, Insulin Pumps, and Automated Insulin Delivery Technology.
- External continuous subcutaneous insulin infusion pumps are medically necessary for managing individuals with diabetes due to other causes that require intensive insulin therapy (insulin-treated at least 3 times a day). Examples include but are not limited to cystic fibrosis-related diabetes, post-transplantation diabetes, or diabetes following pancreatic surgery.
- 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."
- Duration of authorization: "Initial CGM authorization will be for up to six months. Reauthorization will be for up to 12 months."
- Long-term (greater than 14 days) non-implantable CGM for individuals requiring intensive insulin therapy: "When used according to FDA labeled indications, contraindications, warnings, and precautions, initial long-term CGM use is proven and medically necessary in certain circumstances." (Medical necessity clinical coverage criteria: InterQual® CP.)
- Continued long-term non-implantable CGM (intensive insulin therapy): Medically necessary when all of the following criteria are met: - Device is used according to FDA labeled indications, contraindications, warnings, and precautions - Medical necessity clinical coverage criteria are met; refer to the InterQual® CP - Individual is assessed by a provider every six months for adherence to the prescribed CGM regimen and treatment plan.
3 Active Policies
UHC-POL-continuous-glucose-monitoring-insulin-delivery-managing-diabetes — Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes
UMR-POL-UMR-continuous-glucose-monitoring-insulin-delivery-managing-diabetes — Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes
SUREST-POL-SUREST-continuous-glucose-monitoring-insulin-delivery-managing-diabetes — Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes
Related Codes
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