Medicare Changes to CGM Coverage

Continuous glucose monitors (CGMs) have become an integral piece of managing diabetes and have been steadily gaining popularity in recent years. Unfortunately, one of the biggest barriers to obtaining a CGM is insurance coverage and high out-of-pocket cost. On June 3, 2021, Medicare announced some changes that will make obtaining a CGM more accessible for people with diabetes. This recent change in coverage criteria is the first of many steps to making these devices more available for people with diabetes!

New 2021 Medicare CGM coverage criteria

The updated Medicare CGM coverage criteria will begin on July 18th, 2021, and will include the following changes:1

  1. ELIMINATES the four times per day testing requirement in order to qualify for coverage.
  2. INCLUDES people using multiple daily administrations (changed from injections), of any insulin to qualify. This change in wording will make those who use inhaled insulin eligible.

Additional Medicare CGM qualifying criteria will continue to include the following requirements:1

  1. The beneficiary has a diagnosis of diabetes mellitus (either type 1 or type 2).
  2. The beneficiary is insulin-treated with multiple (>3) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) pump.
  3. The beneficiary’s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results.
  4. The beneficiary is seen by their provider within 6 months of ordering the CGM and is seen every 6 months following the initial prescription.

What is a continuous glucose monitor?

A continuous glucose monitor is a device that is worn on your body and continuously monitors your blood sugar in real-time. A small sensor sits under your skin and generates a new blood glucose reading every few minutes.

What are the benefits of a CGM?

  • Monitors blood sugars every few minutes which provides hundreds of blood sugars daily
  • Helps detect blood sugars patterns and trends at various time frames throughout the day and night
  • Helps you understand various factors such as: how what you eat and your level of activity affect blood sugars
  • It can alarm or alert you when approaching both high and low levels
  • It can reduce or eliminate the need for finger sticks
  • Some CGMs have the ability to be integrated with an insulin pump
  • Some CGMs utilize blue tooth and allow you to monitor your blood sugar on your phone, tablet or watch
  • Some allow you to connect and share data with others, such as your family, friends your healthcare team

How do I get a CGM?

Talking with your healthcare team to see if a CGM is right for you is always the first step. Your team may help you decide which CGM is the best fit for you. Coverage and cost vary depending on your insurance plan, and will also require a prescription or order from your doctor. CGMs can either be purchased from a pharmacy or a durable medical equipment company.

What CGMS are currently on the market and how can I get more information?

Here is the full Medicare statement on CGM coverage.

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