S1034, Artificial pancreas device system (e.g., low glucose suspend (lgs) feature)
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
- I.Non-ImplantedContinuous Interstitial Glucose Monitoring Devices for Personal Use
- Use of anon-implantedcontinuous interstitial glucose monitoring device for personal use is consideredmedically necessaryfor individuals who meet the following criteria:
- Individual has been diagnosed with diabetes mellitus (any type);and
- Insulin injections are required multiple times daily or an insulin pump is used for maintenance of blood sugar control;and
- Both of the following (1 and 2):The individual or caregiver(s) demonstrates the following:An understanding of the technology, including use of the device to recognize alerts and alarms;andMotivation to use the device correctly and consistently;andContinued participation in a comprehensive diabetes treatment plan;andAnyof the following are present, despite ongoing management using self-monitoring and insulin administration regimens to optimize care:Inadequate glycemic control, demonstrated by HbA [...]
- The individual or caregiver(s) demonstrates the following:An understanding of the technology, including use of the device to recognize alerts and alarms;andMotivation to use the device correctly and consistently;andContinued participation in a comprehensive diabetes treatment plan;and
6 Active Policies
ANTHEM-CG-DME-42, CG-DME-42 Continuous Glucose Monitoring Devices
ANTHEM-CG-DME-50, CG-DME-50 Automated Insulin Delivery Systems
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
Related Codes
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