A4226, Supplies for maintenance of insulin infusion pump with dosage rate adjustment
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
- Required documentation for automated insulin delivery system review includes history and physical, age, device requested, data showing >3 months of prior insulin pump use, and gestational diabetes/suboptimal glycemic control when applicable.
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage.
Key Coverage Criteria
- External continuous subcutaneous insulin infusion pumps are proven and medically necessary in certain circumstances when used for managing diabetes according to FDA-labeled indications, contraindications, warnings, and precautions.
4 Active Policies
UHC-POL-continuous-glucose-monitoring-insulin-delivery-managing-diabetes, Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes
REGENCE-DME77, Insulin Infusion Pumps, Automated Insulin Delivery and Artificial Pancreas Device Systems
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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