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:

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1. The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses); and,

2. The beneficiary is insulin-treated with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and,

3. The beneficiary’s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and,

4. 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,

5. 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.

 

Source
 

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

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