The content in this website has not been updated since March 29, 2013, and is relevant only to dates of service prior to
April 1, 2013. For more information, visit the Provider Transition Update Center.

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FAQ

External insulin pumps and medically necessary supplies may be considered for coverage if ONE of the following requirements is met:

Cystic fibrosis-related diabetes with fasting hyperglycemia
Gestational diabetes
Type 1 or 2 diabetes mellitus during the pre-pregnancy phase or during pregnancy
Type 1 or 2 diabetes mellitus (including latent autoimmune diabetes) with ALL of the following:
- Treatment regimen includes three or more insulin injections per day with frequent self-adjustments of insulin dose during the six months prior to initiating the insulin pump
- Documented frequency of glucose self-testing is an average of at least four times per day during the two months prior to initiation of the insulin pump
- Glycosylated hemoglobin A1c (HbA1c) level has been completed within the recent three months
- Unstable blood glucose levels as documented by ONE of the following:
  - Glycosylated hemoglobin (HbA1c) greater than 7.0%
  - Recurrent hypoglycemia
  - Wide fluctuations in levels over the past 2 months
  - Dawn phenomenon with fasting blood glucose levels greater than 200
  - Severe glycemic excursions requiring emergency room care or inpatient admissions within the past 12 months
  - Comorbidity resulting from diabetes (such as nephropathy, kidney transplant, neuropathy, retinopathy, gastroparesis)
- Patient has demonstrated compliance with the treatment regimen including diet, blood glucose monitoring, insulin administration, and insulin dose adjustment

Insulin pumps for any condition or indication not included above are considered not covered, unproven, experimental or investigational.

Replacement

External insulin pumps may be considered for replacement if there is documentation of malfunctioning and the pump is no longer under warranty.
OmniPods may be considered for replacement more often than every 72 hours if ONE of the following is met:
- Insulin is not absorbed properly resulting in hyperglycemia prior to the 72 hours expiration
- Frequent infections or abscesses at the injection site

Review date: December 2011