Are Continuous Glucose Monitors Covered by Medicare?

Continuous Glucose Monitors (CGMs) are advanced tools that have transformed diabetes management. These devices provide real-time data on glucose levels throughout the day and night, offering a comprehensive picture that traditional fingerstick testing cannot. By continuously tracking glucose, CGMs empower individuals with diabetes to make informed decisions about diet, exercise, and medication, which can lead to improved health outcomes. Their ability to alert users to high or low glucose levels enhances safety and helps prevent serious complications.

Eligibility for Coverage

Medicare coverage for Continuous Glucose Monitors is determined by specific medical necessity criteria. An individual must have a diagnosis of diabetes mellitus to be considered for coverage. Beyond the diabetes diagnosis, eligibility hinges on the type of diabetes management therapy being used or a history of problematic low blood sugar events.

Individuals who use insulin, regardless of the specific type or amount of insulin, may qualify for coverage. This includes those on intensive insulin therapy, encompassing multiple daily insulin injections and insulin pump use. Additionally, individuals who do not use insulin but have a documented history of problematic hypoglycemia, defined as a level 3 hypoglycemic event requiring third-party assistance, may also be eligible.

A healthcare professional must determine that the CGM is medically necessary for the individual’s specific diabetes management plan. This requires a consultation, which can be in-person or via telehealth, within six months before the CGM is ordered. Ongoing coverage requires regular follow-up visits with the healthcare professional, typically every six months, to ensure continued eligibility and effective device use. The healthcare provider must also confirm that the beneficiary or their caregiver has received adequate training to use the CGM system as prescribed.

Medicare Coverage Specifics

Continuous Glucose Monitors and their associated supplies are covered under Medicare Part B as Durable Medical Equipment (DME). This classification means the devices are long-lasting medical equipment suitable for use in the home. Medicare Part B covers the essential components of a CGM system, which typically include the main device (such as a receiver), the disposable sensors that measure glucose levels, and transmitters that send data from the sensor to the receiver. For Medicare to cover a CGM, the system must include a dedicated receiver, even if the individual also uses a compatible smartphone application to view glucose data.

Medicare generally pays 80% of the Medicare-approved amount for the CGM and its supplies, with the beneficiary responsible for the remaining 20% coinsurance after meeting the annual Medicare Part B deductible. For example, in 2025, the Part B deductible is $257, which must be paid by the beneficiary before Medicare begins its 80% coverage.

While Original Medicare Part B outlines these cost-sharing responsibilities, individuals with supplemental insurance, such as Medigap policies or Medicare Advantage plans, may experience different out-of-pocket costs. Medicare Advantage plans must provide at least the same level of coverage as Original Medicare, but they may have varying premiums, deductibles, copayments, and coinsurance structures. Individuals with these plans should consult their specific plan details to understand their financial obligations for CGM coverage.

Obtaining a CGM

Acquiring a Continuous Glucose Monitor through Medicare involves a structured process, assuming all eligibility criteria have been met. The first step requires consulting with a healthcare provider. During this consultation, the provider will assess the medical necessity of the CGM and issue a prescription or a Standard Written Order for the device and its associated supplies. This order serves as the official documentation for Medicare purposes.

Following the physician’s order, the beneficiary must work with a Medicare-approved Durable Medical Equipment (DME) supplier. Ensure the chosen supplier is enrolled in Medicare and accepts Medicare assignment. Accepting assignment means the supplier agrees to accept the Medicare-approved amount as full payment for the equipment, charging the beneficiary only the applicable coinsurance and deductible. Beneficiaries can find Medicare-approved suppliers through the Medicare website’s supplier directory or by contacting Medicare directly.

The DME supplier plays a central role in handling the billing process directly with Medicare. They will submit the necessary claims, including the physician’s prescription and supporting medical documentation, to ensure proper coverage. The beneficiary receives the CGM device and supplies directly from the supplier, and the supplier manages the financial transactions with Medicare.