Medicare CGM Coverage Criteria

Last week, while many seniors were busy monitoring how the American Health Care Act would affect Medicare, the Centers for Medicare and Medicaid Services (CMS) delivered some positive news for Medicare beneficiaries with diabetes. On Friday, CMS released its criteria for coverage of therapeutic continuous glucose monitoring (CGM) systems; Type 1 and Type 2 diabetes patients covered by Medicare who are on intensive insulin therapy may now get reimbursed for their Dexcom G5 Mobile.

Although the organization determined in January that CGMs qualify as durable medical equipment under Medicare Part B, CMS did not spell out the criteria of how therapeutic CGMs would be covered by Medicare until last week. While there are several CGMs are on the market, Dexcom’s G5 Mobile system is the only CGM classified as “therapeutic” by the US Food and Drug Administration; therefore, it’s the only one covered by Medicare.

According to CMS, therapeutic CGMs may be covered by Medicare when all of the following criteria are met:

• The beneficiary has diabetes mellitus; and,
• The beneficiary has been using a home blood glucose monitor (BGM) and performing frequent (four or more times a day) BGM testing; and,
• The beneficiary is insulin-treated with multiple daily injections (MDI) of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and,
• The patient’s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of therapeutic CGM testing results.

Outlining the criteria for coverage is important news for people on Medicare who have either Type 1 or Type 2 diabetes and intensively manage their insulin. They now know how they will be able to obtain reimbursement if they use Dexcom G5 Mobile (or another CGM that eventually may be approved by the FDA).

“For many years, the Endocrine Society has advocated to expand coverage for CGMs to the Medicare population,” The Endocrine Society, a global leader in the field of hormone research, said in a statement. “The Society is pleased with the new coverage criteria and looks forward to continuing work with CMS to ensure patients have access to these lifesaving tools.”

With this CMS outlining its coverage for CGMs, diabetics on Medicare can use Dexcom G5 Mobile to carefully monitor dangerous surges or drops in blood glucose levels. Unlike with periodic blood sticks, with measurements constantly being taken using CGMs, users can get much more information to plan their insulin dosing regimen and make adjustments as needed.

With Dexcom G5, diabetics are provided with readings every 5 minutes. These readings can be transmitted by Bluetooth to a smartphone or device, and even be monitored remotely by up to 5 people by using an app. By using CGMs, users are better managing their diabetes and leading healthier lives. In fact, a 2016 study concluded that after one year, patients with Type 1 diabetes “showed significant glycemic benefits in using” real-time CGMs.

According to CMS, coverage is effective for CGMs Medicare claims with dates of service on or after January 12, 2017.