ND Committee Review
Internal Medical Policy Committee 3-16-2020 Added replacement criteria, added information about the Omnipod systems, added V-Go disposable insulin delivery device as experimental/investigational
Internal Medical Policy Committee 5-19-2020 Added statement "Members who received the Omnipod Auero’s PDM and supplies between the dates April 1, 2019 and March 31, 2020 and were unable to obtain the DASH Omnipod system through the pharmacy in that timeframe may be eligible for benefits."
Internal Medical Policy Committee 7-22-2020 Minor wording changes, removed A4224, A4225, A4230, A4231 and A4232 from this policy as these codes are part of the Diabetic Services and Supplies policy, and diagnosis codes updated
Internal Medical Policy Committee 7-22-2021 Annual review, no clinical content change
Internal Medical Policy Committee 9-21-2021 Added reauthorization criteria for Omnipod systems
Internal Medical Policy Committee 11-23-2021 Updated criteria wording