Medicare Qualification Criteria
Continuous Glucose Monitors
Therapeutic CGMs and related supplies are covered by Medicare when all of the following coverage criteria (1-6) are met:
1. The beneficiary has diabetes mellitus; and,
2. The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and,
3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare- covered continuous subcutaneous insulin infusion (CSII) pump; and,
4. The beneficiary’s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and,
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and,
6. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in- person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.
When a therapeutic CGM is covered, the related supply allowance for sensors, transmitters, batteries, and calibration supplies are also covered.
Therapeutic CGM devices replace a standard home blood glucose monitor (BGM) and related supplies. Once billing starts for a CGM and the associated supply allowance, Medicare will no longer pay separately for a standard BGM and related supplies.