Guardian 4 continuous glucose sensors and transmitters — United Healthcare
diabetes
Preferred products
- Dexcom G6
- Dexcom G7
- Freestyle Libre
Initial criteria
- Diagnosis of diabetes
- Patient is motivated and knowledgeable about use of continuous glucose monitoring
- Patient is adherent to diabetic treatment plan
- Patient participates in ongoing education and support
- Patient is on an intensive insulin regimen (3 or more insulin injections per day or uses continuous subcutaneous insulin infusion pump) OR Patient has a history of a level 3 hypoglycemic event OR Patient has a history of more than one level 2 hypoglycemia events that persist despite multiple attempts to adjust medication(s) or modify diabetes treatment plan
- Patient regularly monitors blood glucose 4 or more times per day
- Patient has a physical or mental limitation that makes utilization of Dexcom G6 and Dexcom G7 unsafe, inaccurate or otherwise not feasible (e.g. manual dexterity; document limitation) OR Patient has a physical or mental limitation that makes utilization of Freestyle Libre unsafe, inaccurate or otherwise not feasible (e.g. manual dexterity; document limitation)
Reauthorization criteria
- Documentation of positive clinical response
Approval duration
12 months