ND Committee Review
Internal Medical Policy Committee
3-16-2020
- Added
replacement criteria,
and
- Added
information about the Omnipod systems,
and
- 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,
and
- Removed
A4224, A4225, A4230, A4231 and A4232 from this policy as these codes are part of the Diabetic Services and Supplies policy,
and
- Updated
Diagnosis codes
Internal Medical Policy Committee
7-22-2021
Annual review, no clinical content change
Internal Medical Policy Committee
9-21-2021Added
reauthorization criteria for Omnipod systems
Internal Medical Policy Committee
11-23-2021Updated
criteria wording
Internal Medical Policy Committee
5-24-2022Added
Omnipod 5 to the policy
Internal Medical Policy Committee
9-28-2022Effective August 22, 2022
-
Omnipod 5 criteria 'The individual is
six (6)
years of age or older'
updated to
'The individual is
two (2)
years of age or older' based on FDA age indication.
Internal Medical Policy Committee
9-12-2023
Annual review, no clinical content change
Internal Medical Policy Committee 9-17-2024
Effective October 01, 2024
- Removed
insulin delivery systems from general external infusion pump criteria;
and
- Added
insulin delivery systems criteria;
and
- Removed
Omnipod specific initial criteria;
and
- Updated
Omnipod reauthorization criteria
