July 01, 2024

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) L33822open_in_new. 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