Medicare New Guidelines (Update) About CGM System Insurance Coverage

Medicare New Guidelines About CGM systems Insurance Coverage

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Medicare Updates

On March 2, 2023, DME MACs released an updated LCD and Policy Statement for the Glucose Monitors, finalizing the expansion of coverage for continuous glucose monitors (CGMs).

To be qualified for coverage of a CGM and other related items, the recipient must meet the following requirements for coverage.

The recipient must be diagnosed with diabetes Mellitus.

The practitioner treating the beneficiary must verify that the patient is trained in using the CGM prescribed by a prescription.

The CGM is given according to FDA’s guidelines for its use.

The recipient must meet at minimum one of the following requirements:

The person who is the beneficiary should be treated with insulin.

The patient has a challenging medical history of hypoglycemia that includes evidence of at least some of the following conditions:

The condition is recurrent (more than) level 2 hypoglycemic events (Glucose M54mg/dL (3.0mmol/L)), which persists despite multiple (more than) attempts to alter the medication(s) or alter the treatment plan for diabetes

A one-level 3 hypoglycemic episode (Glucose M54mg/dL (3.0mmol/L))) is characterized by an altered physical or medical state requiring assistance from a third party to treat hypoglycemia.

Within six months of making the CGM, The treating physician will conduct an in-person visit or Medicare-approved telehealth session with the patient to assess their diabetes control and determine that the above criteria have been fulfilled.

This policy will take effect on April 16, 2023.

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