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The Policy VaultThe Policy Vault

Guardian 4 continuous glucose sensors and transmittersUnited 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