Medicare Qualification Criteria
Continuous Glucose Monitors (CGMs)
Therapeutic CGMs and related supplies are covered by Medicare when all of the following coverage criteria (1-5) are met:
The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses); and,
The beneficiary is insulin-treated with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and,
The beneficiary’s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and,
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 (1-3) above are met; and,
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 and transmitters 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