New prior authorization requirements for CGMs

Applies to UnitedHealthcare Medicare Advantage plans

Beginning Sept. 1, 2024, UnitedHealthcare® Medicare Advantage plans, including Medicare and Medicaid Dual Special Needs Plans (D-SNPs), will require prior authorization for personal long-term continuous glucose monitors (CGMs) for members with any diagnosis other than Type 1 diabetes. When the durable medical equipment (DME) vendor receives a physician order for a CGM, the DME provider must obtain prior authorization for both the device and the supplies. The prior authorization will be effective for a consecutive 12-month period. 

This aligns with the Centers for Medicare & Medicaid Services Local Coverage Determination (LCD) L33822. It allows members who require insulin or have problematic hypoglycemia to appropriately receive a CGM in accordance with Medicare guidelines.

Exclusions

The new requirement doesn’t apply to the following:

• Ohio D-SNP
• Tennessee D-SNP
• Tennessee Fully Integrated Dual Eligible (FIDE-SNP) plans

In addition, this requirement doesn’t apply to members with Type 1 diabetes because these members meet the clinical criteria for CGMs. Providers don’t need to request prior authorization to fill CGM and supply orders for these patients. If a DME provider submits a prior authorization for a CGM for a member with Type 1 diabetes, they’ll receive a message that prior authorization isn’t necessary.

Applicable codes

This new requirement applies to the following Healthcare Common Procedure Codes (HCPCs):

• A4238: Supply allowance for adjunctive, non-implanted continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service
• A4239: Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service
• E2102: Adjunctive, non-implanted continuous glucose monitor or receiver
• E2103: Non-adjunctive, non-implanted continuous glucose monitor or receiver

Submit a prior authorization request

You can request prior authorization through the UnitedHealthcare Provider Portal:

• From any page on UHCprovider.com, select Sign In at the top-right corner
• Enter your One Healthcare ID
  • New users who don’t have a One Healthcare ID: Visit UHCprovider.com/access to get started
• From the left-hand tabs, select Prior Authorizations & Notifications. Then, click “Create a new request.”
• Select the appropriate prior authorization type from the dropdown
• Enter the required information and click Continue

More information

To learn more, please see our Changes to continuous glucose monitor prior authorization requirement frequently asked questions.

Questions?

If you have questions, please reach out to your network contact.

PCA-1-24-00399-Clinical-NN_06182024