Point32 Diabetes Management Devices/CGMS Form

Harvard Pilgrim HealthCare

Medical Policy

Diabetes Management Devices

STRIDESM (HMO) MEDICARE ADVANTAGE

Subject: Diabetes Management Devices

Authorization: Prior authorization from Harvard Pilgrim StrideSM (HMO) Medicare Advantage is required for all diabetes management devices.

Policy and Coverage Criteria:

Harvard Pilgrim Health Care (HPHC) utilizes Centers for Medicare and Medicaid Services (CMS) guidelines and applicable National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) for medical necessity determination.