CGM Coverage Criteria According to CMS
According to the Centers for Medicare & Medicaid Services, code L33822, there are some requirements for getting a Continuous Glucose Monitor (CGM) through your insurance. Keep in mind that policies can vary between states, so specific requirements may differ based on your location.
To qualify for coverage of a CGM (Continuous Glucose Monitor)
You must meet the following criteria:
Diagnosis
You must have diabetes mellitus. Check the specific ICD-10 codes for eligible diagnoses.
Training
Your healthcare provider must confirm that you or your caregiver have received sufficient training on how to use the prescribed CGM.
FDA Approval
The CGM must be prescribed according to its FDA-approved uses.
Glycemic Control
To improve blood sugar control, you need to meet one of these conditions:
- You are treated with insulin.
- You have a history of problematic low blood sugar (hypoglycemia). This includes:
- Multiple level 2 hypoglycemic events (blood sugar below 54 mg/dL) that persist despite attempts to adjust medications.
- One level 3 hypoglycemic event, which requires assistance.
Recent Evaluation
Within six months before ordering the CGM, your healthcare provider must have an in-person or Medicare-approved telehealth visit to assess your diabetes management.
IMPORTANT:
This information is for those having Medicare, Medicaid and their Advantages Plans. Individuals with different commercial insurances may either check directly with their insurance companies OR simply fill out this Benefit Check Form and leave the rest on CGM Monitors.