V-Go device — Medical Mutual

Initial criteria

• Patient age ≥ 18 years; AND
• Patient requires continuous subcutaneous infusion of either 20 Units, 30 Units, or 40 Units of basal insulin in a 24-hour time period AND on-demand dosing of up to 36 Units of bolus insulin in a 24-hour time period; AND
• Patient must be using a rapid-acting insulin product (U-100 only) in the device; AND
• Patient has been using multiple doses of insulin injections a day (3 injections daily or more); AND
• Patient has worked with a provider to adjust dose of insulin for at least 6 months and failed to meet glucose goals; AND
• Patient does not need to make regular adjustments or modifications to their basal rate during a 24-hour period, OR patient’s amount of bolus insulin used does not require adjustments of less than 2 unit increments; AND
• Patient meets ONE of the following while on insulin: HbA1c > 7%; OR history of recurring hypoglycemia; OR wide fluctuations in blood glucose before mealtime; OR dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL; OR history of severe glycemic excursions; AND
• Patient has tried and failed an external insulin pump (failure such as: blood glucose control cannot be maintained on an external pump OR member has barriers that cannot allow the use of an external pump) [documentation required]; AND
• Patient’s total daily insulin requirement does not exceed 76 units.

Reauthorization criteria

• Patient age ≥ 18 years; AND
• Patient requires continuous subcutaneous infusion of either 20 Units, 30 Units, or 40 Units of basal insulin in a 24-hour time period AND on-demand dosing of up to 36 Units of bolus insulin in a 24-hour time period; AND
• Patient is using a rapid-acting insulin product (U-100 only) in the device; AND
• Patient’s total daily insulin requirement does not exceed 76 units; AND
• Patient is currently on the V-Go device OR member has tried and failed an external insulin pump (failure such as: blood glucose control cannot be maintained on an external pump OR member has barriers that cannot allow the use of an external pump) [documentation required].

Approval duration

1 year initial, 1 year reauth