Prior authorization request form Form

Effective Date

Last Reviewed

Original Document

Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the member meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request preauthorization or post-payment review. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. This clinical policy is not intended to pre-empt the judgment of the reviewing medical director or dictate to health care providers how to practice medicine. Health care providers are expected to exercise their medical judgment in rendering appropriate care. Health care providers are expected to exercise their medical judgment in rendering appropriate care.
EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary.
If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. Identification of selected brand names of devices, tests and procedures in a medical coverage policy is for reference only and is not an endorsement of any one device, test or procedure over another. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication.
EmblemHealth may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. EmblemHealth Services Company, LLC, has adopted this policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC, and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Definitions Pumps External insulin infusion
Programmable, battery-powered mechanical syringe/reservoir devices controlled by a micro- computer to provide continuous subcutaneous insulin infusion (CSII). Sensor-augmented
Suspend insulin when glucose is low or predicted to go low within the next 30 minutes. Continuous Glucose Monitoring (CGM) Real-time CGM (rtCGM) CGM systems that measure and display glucose levels continuously. Intermittently scanned CGM (isCGM) with and without alarms CGM systems that measure glucose levels continuously but require scanning for visualization and storage of glucose values. Professional CGM CGM devices that are placed on the patient in the provider’s office (or with remote instruction) and worn for a discrete period of time (generally 7–14 days). Data may be blinded or visible to the person wearing the device. The data are used to assess glycemic patterns and trends. Unlike rtCGM and isCGM devices, these devices are clinic-based and not owned by the person with diabetes.

Page 2 of 13 Implantable interstitial glucose sensors (also referred to as Implantable Continuous Glucose Monitor [ICG-M]) Implantable Continuous Glucose Monitor (ICG- M) Device that provides real-time glucose monitoring every five minutes for up to 90 days at a time. The system consists of an implantable fluorescence-based sensor, a smart transmitter, and a mobile application for displaying glucose values, trends and alerts on the patient's compatible mobile device. It is designed to replace fingerstick blood glucose testing. Automated Insulin Delivery Systems (combined functionality) Automated Insulin Delivery System Increase and decrease insulin delivery based on sensor derived glucose level to begin to approximate physiologic insulin delivery. These systems consist of three components:  Insulin pump  Continuous glucose sensor  Algorithm that determines insulin delivery
With these systems, insulin delivery can not only be suspended but also increased or decreased based on sensor glucose values. Guidelines A. External insulin infusion pumps B. Personal CGM devices C. Automated Insulin Delivery Systems D. Implantable Interstitial Glucose Sensors (Commercial and Medicare)

A. External insulin infusion pumps External insulin infusion pumps (including but not limited to tubeless disposable pumps such as the OmniPod®, Omnipod Dash, Tandem Mobi, Twiist, and iLet) are considered medically necessary for Type 1, Type 2 or gestational diabetes when the member or caregiver is able to hear, view and appropriately respond to device alerts.

B. Personal CGM devices Personal CGM devices (including but not limited to Medtronic Guardian Connect, Dexcom G7, FreeStyle Libre 3, etc.) are considered medically necessary for diabetes when criteria under Section A is met. Note regarding EmblemHealth: Members on a commercial plan do not require the criteria under Section A to be met for personal CGM coverage. C. Automated Insulin Delivery Systems Automated Insulin Delivery Systems (including but not limited to MiniMed 670G, 770G, and 780G [Medtronic], OmniPod 5, T:slimX [Tandem], etc.) are considered medically necessary for diabetes when criteria under Section A is met.

D. Implantable interstitial glucose sensors Implantable Continuous Glucose Monitors (Eversense®) are considered medically necessary for Commercial and Medicare members ≥ 18 years of age with diabetes when criteria under Section A is met.

Page 3 of 13 Limitations and Exclusions

Only FDA-approved devices are covered (including but not limited to alternate controller enabled [ACE] devices such as the t:Slim X2).
Replacement of a pump or a continuous glucose monitor is considered medically necessary when the device is malfunctioning, cannot be refurbished, and is out of warranty.
Combination devices that include a home blood glucose monitor combined with a blood pressure monitor, cholesterol screening analyzer, or other devices (e.g., cellular telephone), not specifically indicated for the management of diabetes mellitus, are regarded as not medically necessary convenience items.
The following devices are not considered medically necessary due to insufficient evidence of therapeutic value:  Implantable insulin pumps  Nonprogrammable disposable insulin delivery systems without wireless communication capability (e.g., V-Go® Disposable Insulin Delivery Device)  Remote wireless glucose monitoring devices (e.g., mySentry)
For Medicare information regarding the use of smart devices (watch, smartphone, tablet, laptop computer, etc.) in conjunction with a therapeutic continuous glucose monitor (CGM) see Noridian Glucose Monitor Policy Article Procedure Codes
0446T Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training (cover for Medicare and Commercial only) 0447T Removal of implantable interstitial glucose sensor from subcutaneous pocket via incision (cover for Medicare and Commercial only) 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 (cover for Medicare and Commercial only) 95249 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; patient-provided equipment, sensor placement, hook- up, calibration of monitor, patient training, and printout of recording
95250 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording.
95251 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; interpretation and report.
A4221 Supplies for maintenance of drug infusion catheter, per week (list drug separately) A4224 Supplies for maintenance of insulin infusion catheter, per week
A4225 Supplies for external insulin infusion pump, syringe type cartridge, sterile, each
A4226 Supplies for maintenance of insulin infusion pump with dosage rate adjustment using therapeutic continuous glucose sensing, per week
A4230 Infusion set for external insulin pump, non-needle cannula type

Page 4 of 13 A4231
Infusion set for external insulin pump, needle type A4232 Syringe with needle for external insulin pump, sterile, 3 cc A4233
Replacement battery, alkaline (other than J cell), for use with medically necessary home blood glucose monitor owned by patient, each A4234 Replacement battery, alkaline, J cell, for use with medically necessary home blood glucose monitor owned by patient, each A4235 Replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by patient, each A4236 Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by patient, each A4238 Supply allowance for adjunctive continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service
A4244 Alcohol or peroxide, per pint A4245 Alcohol wipes, per box A4246 Betadine or pHisoHex solution, per pint A4247 Betadine or iodine swabs/wipes, per box A4250 Urine test or reagent strips or tablets (100 tablets or strips) A4253 Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips A4255 Platforms for home blood glucose monitor, 50 per box A4256 Normal, low, and high calibrator solution/chips A4257 Replacement lens shield cartridge for use with laser skin piercing device, each A4258 Spring-powered device for lancet, each A4259 Lancets, per box of 100 A4271 Integrated lancing and blood sample testing cartridges for home blood glucose monitor, per month
A9274 External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories A9276 Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, 1 unit = 1 day supply A9277 Transmitter; external, for use with interstitial continuous glucose monitoring system A9278 Receiver (monitor); external, for use with interstitial continuous glucose monitoring system A9999 Miscellaneous DME supply or accessory, not otherwise specified E0607 Home blood glucose monitor E0784 External ambulatory infusion pump, insulin E0787 External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuous glucose sensing

Page 5 of 13 E1399 Durable medical equipment, miscellaneous E2100 Blood glucose monitor with integrated voice synthesizer E2101 Blood glucose monitor with integrated lancing/blood sample E2102 Adjunctive continuous glucose monitor or receiver
G0308 Creation of subcutaneous pocket with insertion of 180 day implantable interstitial glucose sensor, including system activation and patient training (Medicare Only) G0309 Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new 180 day implantable sensor, including system activation (Medicare Only) G0564 Creation of subcutaneous pocket with insertion of 365 day implantable interstitial glucose sensor, including system activation and patient training (Medicare only) G0565 Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new 365 day implantable sensor, including system activation (Medicare only) K0553 Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 Unit of Service
K0554 Receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system

ICD-10 Diagnoses E10.10 Type 1 diabetes mellitus with ketoacidosis without coma E10.11 Type 1 diabetes mellitus with ketoacidosis with coma E10.21 Type 1 diabetes mellitus with diabetic nephropathy E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease
E10.29 Type 1 diabetes mellitus with other diabetic kidney complication
E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema E10.3211 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E10.3212 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E10.3213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3219 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E10.3291 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye
E10.3292 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E10.3293 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3299 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E10.3311 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E10.3312 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E10.3313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3319 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
E10.3391 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye

Page 6 of 13 E10.3392 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E10.3393 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3399 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E10.3411 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E10.3412 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
E10.3413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3419 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye
E10.3491 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
E10.3492 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E10.3493 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3499 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
E10.3511 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye
E10.3512 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye
E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E10.3519 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye
E10.3521 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E10.3522 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E10.3523 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E10.3529 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye
E10.3531 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E10.3532 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E10.3533 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E10.3539 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye
E10.3541 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E10.3542 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E10.3543 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E10.3549 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye

Page 7 of 13 E10.3551 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye
E10.3552 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye
E10.3553 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E10.3559 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye
E10.3591 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye
E10.3592 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye
E10.3593 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E10.3599 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye
E10.36 Type 1 diabetes mellitus with diabetic cataract E10.37X1 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E10.37X2 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye
E10.37X3 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral
E10.37X9 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye
E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy
E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy
E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
E10.44 Type 1 diabetes mellitus with diabetic amyotrophy
E10.49 Type 1 diabetes mellitus with other diabetic neurological complication
E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E10.59 Type 1 diabetes mellitus with other circulatory complications E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy E10.618 Type 1 diabetes mellitus with other diabetic arthropathy
E10.620 Type 1 diabetes mellitus with diabetic dermatitis
E10.621 Type 1 diabetes mellitus with foot ulcer
E10.622 Type 1 diabetes mellitus with other skin ulcer
E10.628 Type 1 diabetes mellitus with other skin complications
E10.630 Type 1 diabetes mellitus with periodontal disease
E10.638 Type 1 diabetes mellitus with other oral complications
E10.641 Type 1 diabetes mellitus with hypoglycemia with coma
E10.649 Type 1 diabetes mellitus with hypoglycemia without coma
E10.65 Type 1 diabetes mellitus with hyperglycemia E10.69 Type 1 diabetes mellitus with other specified complication E10.8 Type 1 diabetes mellitus with unspecified complications

Page 8 of 13 E10.9 Type 1 diabetes mellitus without complications
E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) 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 mellitus with unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E11.3211 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E11.3212 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E11.3213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3219 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E11.3291 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye
E11.3292 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E11.3293 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3299 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3311 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E11.3312 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E11.3313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3319 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
E11.3391 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E11.3392 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E11.3393 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3399 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3411 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E11.3412 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
E11.3413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3419 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye
E11.3491 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
E11.3492 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E11.3493 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3499 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3511 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye

Page 9 of 13 E11.3512 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye
E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E11.3519 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye
E11.3521 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E11.3522 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E11.3523 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E11.3529 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye
E11.3531 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E11.3532 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E11.3533 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E11.3539 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye
E11.3541 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E11.3542 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E11.3543 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E11.3549 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye
E11.3551 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye
E11.3552 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye
E11.3553 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E11.3559 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye
E11.3591 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye
E11.3592 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye
E11.3593 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E11.3599 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye
E11.36 Type 2 diabetes mellitus with diabetic cataract E11.37X1 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E11.37X2 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye
E11.37X3 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral
E11.37X9 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye

Page 10 of 13 E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy
E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy
E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy
E11.44 Type 2 diabetes mellitus with diabetic amyotrophy
E11.49 Type 2 diabetes mellitus with other diabetic neurological complication
E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E11.59 Type 2 diabetes mellitus with other circulatory complications
E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy
E11.618 Type 2 diabetes mellitus with other diabetic arthropathy
E11.620 Type 2 diabetes mellitus with diabetic dermatitis
E11.621 Type 2 diabetes mellitus with foot ulcer
E11.622 Type 2 diabetes mellitus with other skin ulcer
E11.628 Type 2 diabetes mellitus with other skin complications
E11.630 Type 2 diabetes mellitus with periodontal disease
E11.638 Type 2 diabetes mellitus with other oral complications
E11.641 Type 2 diabetes mellitus with hypoglycemia with coma
E11.649 Type 2 diabetes mellitus with hypoglycemia without coma
E11.65 Type 2 diabetes mellitus with hyperglycemia E11.69 Type 2 diabetes mellitus with other specified complication E11.8 Type 2 diabetes mellitus with unspecified complications E11.9 Type 2 diabetes mellitus without complications
O24.011 Pre-existing type 1 diabetes mellitus, in pregnancy, first trimester O24.012 Pre-existing type 1 diabetes mellitus, in pregnancy, second trimester O24.013 Pre-existing type 1 diabetes mellitus, in pregnancy, third trimester O24.019 Pre-existing type 1 diabetes mellitus, in pregnancy, unspecified trimester O24.02 Pre-existing type 1 diabetes mellitus, in childbirth O24.03 Pre-existing type 1 diabetes mellitus, in the puerperium O24.111 Pre-existing type 2 diabetes mellitus, in pregnancy, first trimester O24.112 Pre-existing type 2 diabetes mellitus, in pregnancy, second trimester O24.113 Pre-existing type 2 diabetes mellitus, in pregnancy, third trimester O24.119 Pre-existing type 2 diabetes mellitus, in pregnancy, unspecified trimester O24.12 Pre-existing type 2 diabetes mellitus, in childbirth O24.13 Pre-existing type 2 diabetes mellitus, in the puerperium

Page 11 of 13 O24.410 Gestational diabetes mellitus in pregnancy, diet controlled O24.414 Gestational diabetes mellitus in pregnancy, insulin controlled O24.419 Gestational diabetes mellitus in pregnancy, unspecified control O24.420 Gestational diabetes mellitus in childbirth, diet controlled O24.424 Gestational diabetes mellitus in childbirth, insulin controlled O24.429 Gestational diabetes mellitus in childbirth, unspecified control O24.430 Gestational diabetes mellitus in the puerperium, diet controlled O24.434 Gestational diabetes mellitus in the puerperium, insulin controlled O24.439 Gestational diabetes mellitus in the puerperium, unspecified control References American Diabetes Association. Standards of Medical Care in Diabetes. 2026. https://diabetesjournals.org/care/issue/46/Supplement_1. Accessed March 13, 2026. Garg SK, Weinzimer SA, Tamborlance WV, et al. Glucose outcomes in the in-home use of a hybrid closed-loop insulin delivery system in adolescents and adults with type 1 diabetes [published online January 30, 2017]. Diabetes Technol Ther. 2017; doi:10.1089/dia.2016.0421.
Noridian Health Solutions. Local Coverage Determination (LCD) for Glucose Monitors. October 2024. https://www.cms.gov/medicare-coverage- database/view/lcd.aspx?lcdid=33822&ver=48&keywordtype=starts&keyword=glucose%20monitors&bc=0. Accessed March 13,

Noridian Health Solutions. Medicare Local Coverage Decision. External Infusion Pumps. January 2026. https://med.noridianmedicare.com/documents/2230703/7218263/External+Infusion+Pumps+LCDv . Accessed March 24, 2025. Tamborlane WV, Beck RW, Bode BW, et.al. Continuous glucose monitoring and intensive treatment of type 1 diabetes. N Engl J Med 2010; 363:311-320July 22, 2010. Peters AL, et al. Diabetes technology—continuous subcutaneous insulin infusion therapy and continuous glucose monitoring in adults: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016 Sep 2:jc20162534. Accessed July 10, 2018.
Grunberger, George, et al. "American Association of Clinical Endocrinologists and American College of Endocrinology 2018 position statement on integration of insulin pumps and continuous glucose monitoring in patients with diabetes mellitus." Endocrine Practice 24.3 (2018): 302-308. New York State Department of Health. Updated Continuous Glucose Monitoring Criteria. https://www.emedny.org/ProviderManuals/DME/PDFS/Glucose_Monitoring_Criteria_-_10-2-23.pdf. Accessed March 13, 2026. Specialty-matched clinical peer review. Revision History Company(ies) DATE REVISION EmblemHealth 3/13/2026 Updated device versions EmblemHealth 3/14/2025 Transferred policy content to individual company branded template EmblemHealth
ConnectiCare
3/8/2024 Updated definitions and device versions EmblemHealth
ConnectiCare
10/1/2023 Removed insulin frequency adjustments as a prerequisite.

Page 12 of 13 Company(ies) DATE REVISION EmblemHealth
ConnectiCare
6/11/1021 Removed glucose testing prerequisite
Added note to CGM section communicating that Commercial members are not required to meet criterion A. Removed prerequisite pertaining to new pump requests (for newly enrolled members whose pumps were supplied from another insurance plan), which required glucose testing frequency information to be submitted. EmblemHealth
ConnectiCare
1/8/2021 Updated definitions and device versions. Added Commercial and Medicare coverage for Eversense® ICG-M. EmblemHealth
ConnectiCare
5/12/2020 Removed prerequisite for devices to be prescribed by endocrinologists or maternal fetal medicine specialists only. EmblemHealth
ConnectiCare
5/8/2020 Removed hypoglycemic unawareness prerequisite for long-term combined monitoring/insulin delivery devices. EmblemHealth

5/10/2019 Added Type 2 diabetes to long-term combined CGM/insulin-delivery devices section to coincide with FDA approvals. Added implantable glucose sensors (e.g., Eversense®) as investigational. Added pump/CGM replacement criteria.
EmblemHealth

4/12/2019 Added coverage of the t:slim X2.
EmblemHealth

3/9/2019 Added t:slim X2 Insulin Pump to Limitations/Exclusions as investigational. EmblemHealth

6/8/2018 Added hypoglycemic unawareness to long-term criteria. EmblemHealth

5/3/2018 For long term usage; combined the section for single external insulin delivery infusion pumps with the section for combined CGM/Insulin-delivery devices (with the addition of real-time monitoring devices) to create a single section with simplified criteria. Added that combination devices that include a home blood glucose monitor combined with a blood pressure monitor, cholesterol screening analyzer, or other devices (e.g., cellular telephone) not specifically indicated for the management of diabetes mellitus, are regarded as not medically necessary convenience items. EmblemHealth

2/9/2018 Added coverage of the Freestyle Libre Flash Glucose Monitoring System. EmblemHealth

4/7/2017
Added coverage of the Dexcom® G5 for Medicare members only (exclusions apply; listed above).
EmblemHealth

3/10/2017
Communicated that upgrade requests for the MiniMed® 670G System will be reviewed on a case by case basis. EmblemHealth

8/24/2016
Clarified that remote wireless and smartphone capabilities are not considered medically necessary. EmblemHealth

8/5/2016
Added OmniPod® clarification to differentiate from V-Go®.

Page 13 of 13 Revision History 3/8/2024 Updated definitions and device versions. 10/1/2023 Removed insulin frequency adjustments as a prerequisite. 6/11/1021 Removed glucose testing prerequisite
Added note to CGM section communicating that Commercial members are not required to meet criterion A. Removed prerequisite pertaining to new pump requests (for newly enrolled members whose pumps were supplied from another insurance plan), which required glucose testing frequency information to be submitted. 1/8/2021 Updated definitions and device versions. Added Commercial and Medicare coverage for Eversense® ICG-M. 5/12/2020 Removed prerequisite for devices to be prescribed by endocrinologists or maternal fetal medicine specialists only. 5/8/2020 Removed hypoglycemic unawareness prerequisite for long-term combined monitoring/insulin delivery devices. 5/10/2019 Added Type 2 diabetes to long-term combined CGM/insulin-delivery devices section to coincide with FDA approvals. Added implantable glucose sensors (e.g., Eversense®) as investigational. Added pump/CGM replacement criteria.
4/12/2019 Added coverage of the t:slim X2.
3/9/2019 Added t:slim X2 Insulin Pump to Limitations/Exclusions as investigational. 6/8/2018 Added hypoglycemic unawareness to long-term criteria. 5/3/2018 For long term usage; combined the section for single external insulin delivery infusion pumps with the section for combined CGM/Insulin-delivery devices (with the addition of real-time monitoring devices) to create a single section with simplified criteria. Added that combination devices that include a home blood glucose monitor combined with a blood pressure monitor, cholesterol screening analyzer, or other devices (e.g., cellular telephone) not specifically indicated for the management of diabetes mellitus, are regarded as not medically necessary convenience items. 2/9/2018 Added coverage of the Freestyle Libre Flash Glucose Monitoring System. 4/7/2017
Added coverage of the Dexcom® G5 for Medicare members only (exclusions apply; listed above).
3/10/2017
Communicated that upgrade requests for the MiniMed® 670G System will be reviewed on a case by case basis. 8/24/2016
Clarified that remote wireless and smartphone capabilities are not considered medically necessary. 8/5/2016
Added OmniPod® clarification to differentiate from V-Go®.

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