March 2023 Update

HUGE CHANGE COMING APRIL 16th 2023!

Medicare just announced it’s changing the eligibility requirements for CGM systems.  This change will lower the requirements for CGM systems.  It’s estimated that people with diabetes who are eligible for a CGM system will double.  Contact us today to reserve your CGM system. 

To be eligible for coverage of a CGM and related supplies, the beneficiary must meet all of the following initial coverage criteria (a)-(e):

1. 1. The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses); and,
   2. The beneficiary’s treating practitioner has concluded that the beneficiary (or beneficiary’s caregiver) has sufficient training using the CGM prescribed as evidenced by providing a prescription; and,
   3. The CGM is prescribed in accordance with its FDA indications for use; and,
   4. The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the criteria below:
      • The beneficiary is insulin-treated; or,
      • The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the following (see the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section of the LCD-related Policy Article (A52464)):
      • Recurrent (more than one) level 2 hypoglycemic events (glucose <54mg/dL (3.0mmol/L)) that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan; or,
      • A history of one level 3 hypoglycemic event (glucose <54mg/dL (3.0mmol/L)) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia
   5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare-approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria (1)-(4) above are met. 

January 2023 Update

Proposed changes to the Medicare guidelines for CGM eligibility.  It’s probable that these changes will be implemented in Q2 or Q3 2023 as they were submitted with a request for comments in November 2022. 

To be eligible for coverage of a CGM and related supplies, the beneficiary must meet all of the following initial coverage criteria (1)-(5):

• • The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses); and,
  • The beneficiary’s treating practitioner has concluded that the beneficiary (or beneficiary’s caregiver) has sufficient training using the CGM prescribed as evidenced by providing a prescription; and,
  • The CGM is prescribed in accordance with its FDA indications for use; and,
  • The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the criteria below:
    
    • The beneficiary is insulin-treated with at least one daily administration of insulin; or,
    • The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the following:
      
      • Recurrent level 2 hypoglycemic events (glucose <54mg/dL (3.0mmol/L) that persist despite multiple (2 or more) attempts to adjust medication(s) and/or modify the diabetes treatment plan; or
      • A history of one level 3 hypoglycemic event (glucose <54mg/dL (3.0mmol/L) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia
  • Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare-approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met.

December 2021 Changes

The Medtronic Guardian CGM was approved for Medicare reimbursement if used in conjunction with a Medtronic pump.  The CGM will NOT QUALIFY for Medicare reimbursement if the patient is not using a Medtronic pump.  

July 2021 Changes

July brought some very substantial changes to Medicare eligibility dramatically increasing the number of people living with Diabetes who qualify with Medicare.

• • The Testing Requirement was Dropped completely:  The requirement to test your blood glucose multiple times per day was dropped and testing is no longer a requirement for qualifying for a CGM.
  • Daily frequency of Insulin injection was lowered:  You no longer need to inject insulin multiple times a day. As long as you are taking insulin regularly in most cases you qualify!
  • Insulin can be taken through injection, inhalation or infusion:  Inhaled insulin was added to the acceptable forms of taking insulin.  Unfortunately, insulin pills currently do not qualify for a CGM eligibility.