C1788 — Port, indwelling (implantable)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For diabetes self-care programs: a physician order from the treating physician and a statement signed by the physician that the service is needed.
- For reflex/diagnostic anti-GAD antibody testing: documentation that the clinical history is ambiguous and that test results will influence patient management.
- For jet injectors as DME: documentation that the member or the member's caregiver is physically unable to use a conventional needle-syringe (e.g., severe arthritis, severe tremors, blindness) and medical necessity justification.
- For reflectance/voice-enabled meters and DME for the visually impaired: documentation of legal blindness (best corrected visual acuity less than 20/200).
Key Coverage Criteria
- Dexcom SHARE (accessory to Dexcom G4 PLATINUM) provides remote mobile communications allowing transmission of glucose levels to up to 5 designated recipients ('followers') for remote monitoring and alert notifications (described as an accessory to Dexcom G4 PLATINUM).
- Implantable continuous glucose monitoring sensors (examples studied: Senseonics/Eversense, other investigational implantable sensors) have been studied for up to 90 days (single-sensor continuous display) and in some pivotal trials demonstrated accuracy (e.g., PRECISE II MARD 8.8%; 91% sensors functional through day 90).
- Continuous glucose monitoring (CGM) in general: the document cites evidence that CGM can improve glycemic control and quality of life in patients with diabetes mellitus (Dehennis et al 2016; Christiansen et al 2018) and summarizes randomized trials and systematic reviews examining CGM use in type 1 and type 2 diabetes.
- Medically necessary quantities of diabetic supplies (test strips and lancets): - For members with diabetes not currently treated with insulin injections, up to 100 test strips and up to 100 lancets every 3 months are considered medically necessary. - For members with diabetes who are currently being treated with insulin injections, up to 300 test strips and up to 300 lancets every 3 months are considered medically necessary. [...]
- Continued use of CGMs for children and adolescents less than 18 years of age with type 1 or type 2 diabetes.
- Continuous glucose monitor and insulin pump with a low glucose suspend feature (e.g., MiniMed 630G) as an equally acceptable alternative to a standard insulin pump and CGM for medically necessary indications.
1 Active Policy
AETNA-CPB-0070 — Diabetes Tests, Programs and Supplies
Related Codes
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