February 01, 2023
Nebraska Medicaid: Continuous glucose monitoring updates
On Jan. 1, 2023, we began covering continuous glucose monitoring (CGM) devices for UnitedHealthcare Community Plan members who have diabetes and meet medical necessity criteria. This applies to long-term therapeutic and short-term diagnostic CGM devices.
Prior authorization codes
We require prior authorization for CGM devices and supplies. Authorizations for CGM devices may be valid for a minimum of 6 months to maximum of 12 months. We’ll authorize supplies for at least 30 days and up to 90 days at a time.
We cover the costs associated with the following prior authorization codes for eligible members:
| HCPCS code | Modifier | Prior authorization required? | Description | Guidance |
|---|---|---|---|---|
| E2102 | NU | Yes | Adjunctive, non-implanted CGM device or receiver | |
| E2102 | RA | Yes | ||
| E2102 | RB | Yes | ||
| E2103 | NU | Yes | Non-adjunctive, non-implanted CGM device or receiver | |
| E2103 | RA | Yes | ||
| E2103 | RB | Yes | ||
| A4238 | Yes | Supply allowance for adjunctive, non-implanted CGM, includes all supplies and accessories, 1 month supply + 1 unit of service | Initial PA is 6 months, renewal PA is required annually | |
| A4239 | Yes | Supply allowance for non-adjunctive, non-implanted CGM, includes all supplies and accessories, 1 month supply +1 unit of service | Initial PA is 6 months, renewal PA is required annually |
| CPT® code | Modifier | Prior authorization required? | Description | Guidance |
|---|---|---|---|---|
| 95249 | No | Ambulatory CGM of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; patient-provided equipment, sensor placement, hook-up, calibration of monitor, patient training, and printout of recording | This code is covered when the beneficiary begins using a new CGM device, up to once per year | |
| 95250 | No | Ambulatory CGM of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; physician or other qualified healthcare professional-(office) provided equipment, sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording | This code is covered up to 4 times per year | |
| 95251 | No | Ambulatory CGM of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; analysis, interpretation, and report | This code is covered up to 8 times per year |
Resources
- For current fee-for-service information, please visit the Nebraska Department of Health and Human Services’ Medicaid Provider Bulletins page
- For coverage criteria information, please see our medical policy Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for Nebraska Only)
- For Nebraska-specific prior authorization and notification information, visit our Prior Authorization and Notification page
- To submit electronic pharmacy prior authorization, please visit our Nebraska Community Plan Pharmacy Prior Authorization Forms page
Questions?
Please contact your provider advocate.
