MINIMED 630G Insulin Pump — Medical Mutual

Type 1 or type 2 diabetes mellitus requiring short-term continuous glucose monitoring

Initial criteria

Prescriber is a board-certified endocrinologist, internist, or physician specializing in diabetes management AND is capable of ordering and interpreting continuous glucose monitoring results
Patient has type 1 or type 2 diabetes mellitus
For long-term continuous glucose monitoring: ALL of the following:
- Intensive insulin regimen (4 or more daily insulin injections, or use of continuous subcutaneous insulin infusion pump)
- Patient is educated or scheduled to be educated on use of continuous glucose monitoring
For short-term continuous glucose monitoring: ALL of the following:
- Additional information about blood glucose needed, as indicated by ONE or more of the following:
* Dawn phenomenon, known or suspected
* Hypoglycemic unawareness
* Nocturnal hypoglycemia, known or suspected
* Postprandial hyperglycemia, known or suspected
* Significant change to diabetes treatment regimen (e.g. initiation of insulin, change from multiple-dose insulin to insulin pump therapy)
* Unexplained hyperglycemia
- Monitoring limited to 3 to 14 days

Reapprovals will not be given for instances where equipment was maliciously damaged, neglected, used or misused in a fashion not intended by the manufacturer

365 days (long-term); 14 days (short-term, max 2 approvals/year)