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«PacifiCare’s medical management guidelines represent the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. They are ...»

-- [ Page 70 ] --

2003;111(4 pt 1):790-794.

Continuous Glucose Monitoring and Insulin Pumps for Managing Diabetes - Commercial Medical Management Guideline Chase HP, Kim LM, Owen SL, MacKenzie TA, Klingensmith GJ, Murtfeldt R, Garg SK. Continuous subcutaneous glucose monitoring in children with type 1 diabetes. Pediatrics 2001 Feb;107(2):222-6.

Chee F, Fernando T, van Heerden PV. Closed-loop control of blood glucose levels in critically ill patients. Anaesth Intensive Care. 2002;30(3):295-307.

Chico A, Vida K, Rios P, Sutra M, No vials A. The continuous glucose monitoring system is useful for detecting unrecognized hypoglycemia inpatients with type 1 and type 2 diabetes but is not better than frequent capillary glucose measurements fir improving metabolic control. Dia Care. 2003 Apr;26(4):1153-7.

Children with diabetes. Continuous glucose sensors. Updated March 13, 2008 Available at: http://www.childrenwithdiabetes.com/continuous.htm Accessed February 5, 2009.

Deiss D, Hartmann R, Schmidt J, Kordonouri O. Results of a randomised controlled cross-over trial on the effect of continuous subcutaneous glucose monitoring (CGMS) on glycaemic control in children and adolescents with type 1 diabetes. Exp Clin Endocrinol Diabetes. 2006a Feb;114(2):63-7.

Deiss D, Bolinder J, Riveline JP, Battelino T, Bosi E, Tubiana-Rufi N, Kerr D, Phillip M. Improved glycemic control in poorly controlled patients with type 1 diabetes using real-time continuous glucose monitoring. Diabetes Care. 2006b Dec;29(12):2730-2.

Diabetes Control and Complications Trial (DCCT) Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin dependent diabetes mellitus. N Engl J Med.

1993;329:977-86.

Diabetes Research in Children Network (DirecNet) Study Group, Buckingham B, Beck RW, Tamborlane WV, Xing D, Kollman C, Fiallo-Scharer R, Mauras N, Ruedy KJ, Tansey M, Weinzimer SA, Wysocki T. Continuous glucose monitoring in children with type 1 diabetes. J Pediatr. 2007 Oct;151(4):388-93, 393.e1-2.

Diabetes Research in Children Network (DirecNet) Study Group. Use of the DirecNet Applied Treatment Algorithm (DATA) for diabetes management with a real-time continuous glucose monitor (the FreeStyle Navigator). Pediatr Diabetes. 2008 Jan 24. Epub ahead of print.

Diabetes Research in Children Network (DirecNet) Study Group. Youth and parent satisfaction with clinical use of the Glucowatch G2 Biographer in the management of pediatric type 1 diabetes. Diabetes Care. 2005;28:1929-35.

Diabetes Research in Children Network (DirecNet) Study Group. Psychological aspects of continuous glucose monitoring in pediatric type 1 diabetes. Pediatr Diabetes. 2006;7(1):32-38.

ECRI Institute. TARGET Report 896. Real-time continuous glucose monitoring (CGM). November, 2007.

ECRI Institute. Hotline Response. External Insulin Pump with Continuous Glucose Monitoring System for Diabetes Management. Updated February 2008.

ECRI Institute. Hotline Response. Self-monitoring of Glucose in Patients with Diabetes. August 2007.

Farrar D, Tuffnell DJ, West J. Continuous subcutaneous insulin infusion versus multiple daily injections of insulin for pregnant women with diabetes. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005542.

Continuous Glucose Monitoring and Insulin Pumps for Managing Diabetes - Commercial Medical Management Guideline Fiallo-Scharer R; Diabetes Research in Children Network Study Group. Eight-point glucose testing versus the continuous glucose monitoring system in evaluation of glycemic control in type 1 diabetes. J Clin Endocrinol Metab. 2005 Jun;90(6):3387-91.

Garg SK, Kelly WC, Voelmle MK, Ritchie PJ, Gottlieb PA, McFann KK, Ellis SL.Continuous home monitoring of glucose: improved glycemic control with real-life use of continuous glucose sensors in adult subjects with type 1 diabetes.

Diabetes Care. 2007 Dec;30(12):3023-5.

Garg S, Jovanovic L. Relationship of fasting and hourly blood glucose levels to HbA1c values: safety, accuracy, and improvements in glucose profiles obtained using a 7-day continuous glucose sensor. Diabetes Care. 2006b Dec;29(12):2644-9.

Garg S, Zisser H, Schwartz S, Bailey T, Kaplan R, Ellis S, Jovanovic L. Improvement in glycemic excursions with a transcutaneous, real-time continuous glucose sensor: a randomized controlled trial. Diabetes Care. 2006a Jan;29(1):44-50.

Halvorson M, Carpenter S, Kaiserman K, Kaufman FR. A pilot trial in pediatrics with the sensor-augmented pump:

combining real-time continuous glucose monitoring with the insulin pump. J Pediatr. 2007 Jan;150(1):103-105.e1.

Hayes, Inc. Medical Technology Directory. Continuous Glucose Monitoring Systems. Lansdale PA: Hayes, Inc;

December 2008.

Hayes, Inc. Health Technology Brief. MiniMed Paradigm® Real-Time Closed-Loop Continuous Insulin Infusion and Blood Glucose Monitoring System (Medtronic MiniMed Inc.) Lansdale PA: Hayes, Inc; July 2007. Updated July 2008

Hirsch IB, et al. Presentation at American Diabetes Association 67th Scientific Sessions June 2007, Chicago. Available at:

http://professional.diabetes.org/Abstracts_Display.aspx?TYP=1&CID=54079 Accessed February 5, 2009.

Jeitler K, Horvath K, Berghold A, et al. Continuous subcutaneous insulin infusion versus multiple daily insulin injections in patients with diabetes mellitus: systematic review and meta-analysis. Diabetologia. 2008 Jun;51(6):941-51.





Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group, et al. Continuous glucose monitoring and intensive treatment of type 1 diabetes. N Engl J Med. 2008 Oct 2;359(14):1464-76.

Kestila KK, Ekblad UU, Ronnemaa T. Continuous glucose monitoring versus self-monitoring of blood glucose in the treatment of gestational diabetes mellitus. Diabetes Res Clin Pract. 2007 Aug;77(2):174-9.

Lagarde WH, Barrows FP, Davenport ML, Kang M, Guess HA, Calikoglu AS. Continuous subcutaneous glucose monitoring in children with type 1 diabetes mellitus: a single-blind, randomized, controlled trial. Pediatr Diabetes. 2006 Jun;7(3):159-64.

Larsen J, Ford T, Lyden E, Colling C, Mack-Shipman L, Lane J. What is hypoglycemia in patients with well-controlled type 1 diabetes treated by subcutaneous insulin pump with use of the continuous glucose monitoring system? Endocr Pract. 2004 Jul-Aug;10(4):324-9.

Lee SW, Sweeney T, Clausen D, et al. Combined insulin pump therapy with real-time continuous glucose monitoring significantly improves glycemic control comapred to multiple daily injection therapy in pump napatients with type 1 diabetes; single center pilot study experience. Journal of Diabetes Science and Technology 2007;1(3):400-4.

Ludvigsson J, Hanas R. Continuous subcutaneous glucose monitoring improved metabolic control in pediatric patients Continuous Glucose Monitoring and Insulin Pumps for Managing Diabetes - Commercial Medical Management Guideline with type 1 diabetes: a controlled crossover study. Pediatrics. 2003 May;111(5 Pt 1):933-8.

Mastrototaro JJ, Cooper KW, Soundararajan G, Sanders JB, Shah RV. Clinical experience with an integrated continuous glucose sensor/insulin pump platform: a feasibility study. Adv Ther. 2006 Sep-Oct;23(5):725-32.

Mastrototaro J, Cooper K, Shah R. Early clinical experience with an integrated continuous glucose sensor/insulin pump platform. Diabetes Res Clin Pract. 2006;74(Suppl. 2):S156-S159.

National Institute for Health and Clinical Excellence (NICE) Type 1 diabetes: diagnosis and management of type 1

diabetes in children and young people. Available at:

http://www.nice.org.uk/nicemedia/pdf/CG015childrenfullguideline.pdf. Accessed February 6, 2009.

National Institute for Clinical Excellence (NICE). CG15 Type 1 diabetes in adults. August 2008. Available at:

http://www.nice.org.uk/nicemedia/pdf/CG15FullGuidelineAdultsMain.pdf Accessed February 6, 2009.

National Institute for Clinical Excellence (NICE). CG15 Type 1 diabetes in children and young people. Jul 2004.

Available at: http://www.nice.org.uk/nicemedia/pdf/CG015childrenfullguideline.pdf Accessed February 6, 2009.

Newman SP, Hurel SJ, Cooke D et al. A randomized control trial of continuous glucose monitoring devices on HbA1c the MITRE study. Presentation at American Diabetes Association 67th Scientific Sessions June 2007, Chicago. Available at: http://scientificsessions.diabetes.org/index.cfm?fuseaction=Locator.Search Abstracts&CalledByID=1006 %20Abstract%200115-O. Accessed February 5, 2009.

Peyrot P, Rubin, R.R. Patient-Reported Outcomes (PRO) for an Integrated Real-Time Continuous Glucose Monitoring/Insulin Pump (RT-CGM/CSII) System. Presentation at American Diabetes Association 67th Scientific Sessions June 2007, Chicago. Available: http://professional.diabetes.org/Abstracts_Display.aspx?TYP=1&CID=54169.

Accessed February 5, 2009.

Phillip M, Battelino T, Rodriguez H, et al. Use of insulin pump therapy in the pediatric age-group: consensus statement from the European Society for Paediatric Endocrinology, the Lawson Wilkins Pediatric Endocrine Society, and the International Society for Pediatric and Adolescent Diabetes, endorsed by the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2007 Jun;30(6):1653-62.

Pickup JC, Sutton AJ. Severe hypoglycaemia and glycaemic control in Type 1 diabetes: meta-analysis of multiple daily insulin injections compared with continuous subcutaneous insulin infusion. Diabet Med. 2008 Jul;25(7):765-74.

Pickup J, Mattock M, Kerry S. Glycaemic control with continuous subcutaneous insulin infusion compared with intensive insulin injections in patients with type 1 diabetes: meta-analysis of randomised controlled trials. BMJ. 2002;324:705.

Pohar SL. Subcutaneous open-loop insulin delivery for type 1 diabetes: Paradigm Real-Time System. Issues Emerg Health Technol. 2007 Oct;(105):1-6.

Sachedina N, Pickup JC. Performance assessment of the Medtronic-MiniMed continuous glucose monitoring system and its use for measurement of glycaemic control in type 1 diabetic patients. Diabet. Med. 2003; 20(12):1012-1015.

Silverstein J, Klingensmith G, Copeland K, et al. Care of children and adolescents with type 1 diabetes: a statement of the American Diabetes Association. Diabetes Care. 2005 Jan;28(1):186-212.

Steil GM, Rebrin K, Darwin C, et al. Feasibility of automating insulin delivery for the treatment of type 1 diabetes.

Continuous Glucose Monitoring and Insulin Pumps for Managing Diabetes - Commercial Medical Management Guideline Diabetes. 2006;55(12):3344-3350.

Tanenberg R, Bode B, Lane W, et al. Use of the continuos glucose monitoring system to guide therapy in patients with insulin-treated diabetes: a randomized controlled trial. Mayo Clin Proc. 2004;79(12):1521-1526.

Weinzimer S, Xing D, Tansey M, Fiallo-Scharer R, et al.; Diabetes Research in Children Network (DirecNet) Study Group. FreeStyle navigator continuous glucose monitoring system use in children with type 1 diabetes using glarginebased multiple daily dose regimens: results of a pilot trial Diabetes Research in Children Network (DirecNet) Study Group. Diabetes Care. 2008 Mar;31(3):525-7.

Wolpert HA.The nuts and bolts of achieving end points with real-time continuous glucose monitoring. Diabetes Care.

2008 Feb;31 Suppl 2:S146-9.

Yates K, Milton AH, Dear K, Ambler G. Continuous glucose monitoring-guided insulin adjustment in children and adolescents on near-physiological insulin regimens. Diabetes Care. 2006;29:1512-1517.

Yogev Y, Chen R, Ben-Haroush A, et al. Continuous glucose monitoring for the evaluation of gravid women with type 1 diabetes mellitus. Obstet Gynecol. 2003;101(4):633-638.

History/Updates Policy revision with name change and changes in coverage rationale. CMS information and coding 4/1/2009 updated. HCPCS codes A9274, E0607 and E0784 added. Policy 2008T0347F archived and policy 2008T0245E retired.

Policy revision with name change and changes in coverage rationale. CMS information and coding 1/2/2009 updated. CPT codes 82962 and 83037 removed. HCPCS code E0607 removed. Several ICD 9 diagnosis codes added. Policy 2005T0347E, Glucose Self-Monitoring for the Management of Diabetes Mellitus, archived.

HCPC code A9276 added to policy per Manager, Coding and Integrity.

3/5/2008 HCPC codes A9277 and A9278 added to policy as recommended by Manager, Coding and Integrity.

2/27/2008 CPT codes 83037, 95251 added to Coding Section per direction from the Reimbursement Medical Policy 1/30/2006 Operations Manager.

CPT code 95250 and HCPCS code E0607 added to Coding Section per direction from the Reimbursement 9/27/2005 Medical Policy Operations Manager.

Policy revision with name change. Policy combines three former policies Continuous Interstitial Fluid 9/15/2005 Glucose Monitoring ( 2000T0308C), Noninvasive Glucose Monitoring for the Management (2005T0347D) and Self-Monitoring of Blood Glucose (2000T0154D) which have been archived.

CPT code 82962 plus HCPCS codes S1030 and S1031 added to Coding Section per direction from the 3/8/2004 Reimbursement Medical Policy Operations Manager.

Medicare entry.

2/4/2003 Policy Reformatted 2/28/2002 Continuous Glucose Monitoring and Insulin Pumps for Managing Diabetes - Commercial Medical Management Guideline Contact Information For questions regarding this policy, send an email to the Medical Technology Interpretation Service at medical_drug_interpretation@uhc.com with the word "Medical" in the subject line.

Coding The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this policy are for reference purposes only.

Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.

CPT Codes:

95250 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording 95251 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; interpretation and report

HCPCS Codes:



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