Effective for dates of service beginning April 1, 2018, Harvard Pilgrim is updating our commercial Continuous Glucose Monitoring Systems Medical Review Criteria, which will be renamed Diabetes Management Devices Medical Review Criteria. Updates to the policy include extensive criteria revisions and changes to coverage and prior authorization requirements.
Under the updated policy, prior authorization will be required for the coverage of insulin pumps, which Harvard Pilgrim considers medically necessary for the management of diabetes mellitus when the criteria outlined in the policy are met.
Additionally, Harvard Pilgrim will begin covering the medically necessary use of integrated sensor-augmented pump therapy systems, with prior authorization.
The new policy also includes criteria that must be met for the replacement of a continuous glucose monitoring system, insulin pump, or combined system. Among other criteria required for replacement, the clinician overseeing the member’s diabetic condition must submit documentation in the form of clinical notes or letters supporting the necessity of the device’s replacement and continued use.
For more information, refer to the updated Diabetes Management Devices Medical Review Criteria.