Who is affected by this change?

This affects Excellus BlueCross BlueShield Endocrinology, Internal Medicine, Family Medicine, Pediatrics, OB-GYN providers in NY on Commercial, Medicaid, Medicare Advantage plans.

When does this change take effect?

This change is effective Jan 1, 2026.

What do I need to do?

Already effective January 1, 2026: For initial external insulin pump requests (HCPCS E0784), billing team should confirm the documentation shows the member is on multiple daily insulin injections (at least three per day), requires frequent self-adjustments of insulin dose for at least three months before pump initiation, has completed a comprehensive diabetes education program, and has diabetes that is poorly controlled despite best practices. The member meets the self-testing criterion either by averaging at least three glucose tests per day during the month before initiation or by using a continuous glucose monitor. Replacement CGM transmitters (A9277, E2102) are medically appropriate when the transmitter or receiver is out of warranty (one year) and the device was previously approved by the Health Plan or was in use before the member's coverage effective date. CGM sensor replacements (A4238, A4239, A9276, E2103) are medically appropriate when the device was previously approved by the Health Plan or was in use before the member's coverage effective date. Replacement insulin pumps (E0784) are medically appropriate when the pump has exceeded its four-year warranty and is malfunctioning, or when a child needs a larger insulin reservoir.

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Excellus BlueCross BlueShieldCommercial · Coverage · Diabetes (Endocrinology) · NY · Endocrinology, Internal Medicine, Family Medicine +2 moreHigh impact

Continuous Glucose Monitoring Systems/External Insulin Pump Therapy for Diabetes 1.01.30

Q: Which billing codes are affected?

The following codes are affected: 95249, 95250, 95251, A4226, A4230, A4231, A4232, A4238, A4239, A9274, A9276, A9277, A9278, E0784, E0787, E2102, E2103, S1030, S1031, S1034, S1035, S1036, S1037, S9145, E79.0, P70.2, E10.10, E11.00, E13.00, R73.01, O24.03, O24.13, O24.83, O24.93.

Effective date

Jan 1, 2026

Identified

Jun 20, 2026

Summary

Excellus BlueCross BlueShield medical policy 1.01.30 expanded its criteria for insulin pump requests to include members who use continuous glucose monitoring rather than finger sticks. The December 18, 2025 annual review removed insulin dependency requirements and states that disposable external insulin pumps are no longer investigational. The May 22, 2025 update had changed the initial pump self-testing requirement from four times a day to three times per day, and the prior initiation requirement from two months to one month.

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What to do

Action · 5 steps

01Already effective January 1, 2026: For initial external insulin pump requests (HCPCS E0784), billing team should confirm the documentation shows the member is on multiple daily insulin injections (at least three per day), requires frequent self-adjustments of insulin dose for at least three months before pump initiation, has completed a comprehensive diabetes education program, and has diabetes that is poorly controlled despite best practices.

02The member meets the self-testing criterion either by averaging at least three glucose tests per day during the month before initiation or by using a continuous glucose monitor.

03Replacement CGM transmitters (A9277, E2102) are medically appropriate when the transmitter or receiver is out of warranty (one year) and the device was previously approved by the Health Plan or was in use before the member's coverage effective date.

04CGM sensor replacements (A4238, A4239, A9276, E2103) are medically appropriate when the device was previously approved by the Health Plan or was in use before the member's coverage effective date.

05Replacement insulin pumps (E0784) are medically appropriate when the pump has exceeded its four-year warranty and is malfunctioning, or when a child needs a larger insulin reservoir.

Codes mentioned

952499525095251A4226A4230A4231A4232A4238A4239A9274A9276A9277A9278E0784E0787E2102E2103S1030S1031S1034S1035S1036S1037S9145E79.0P70.2E10.10E11.00E13.00R73.01O24.03O24.13O24.83O24.93

Original notice

Continuous Glucose Monitoring Systems/External Insulin Pump Therapy for Diabetes 1.01.30

excellusbcbs.com · Always check the source before changing claims.

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Continuous Glucose Monitoring Systems/External Insulin Pump Therapy for Diabetes 1.01.30

Summary

Get alerts when payers change rules like this one

What to do

Codes mentioned

Original notice

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