Are Continuous Glucose Monitors Covered by Medicare Part B?

Continuous Glucose Monitors (CGMs) have transformed diabetes management by offering real-time insights into blood sugar levels. These wearable devices continuously track glucose, helping individuals and their healthcare providers make informed decisions about diet, activity, and medication. CGMs provide a more comprehensive picture of glucose trends throughout the day and night compared to traditional fingerstick tests. This continuous data can significantly improve glycemic control and reduce the risk of diabetes-related complications. Medicare Part B can cover CGMs under specific conditions, recognizing their role in effective diabetes care.

Eligibility for Medicare Part B Coverage

Medicare Part B coverage for Continuous Glucose Monitors is determined by specific patient-centric medical criteria. Individuals must have a diagnosis of diabetes mellitus, including both Type 1 and Type 2 diabetes. A central requirement for coverage is that the patient must be insulin-treated, whether through multiple daily injections or a continuous subcutaneous insulin infusion pump.

A treating physician must document the patient’s need for a CGM in their medical records, confirming the insulin treatment regimen requires frequent adjustment based on glucose readings. Medicare has expanded coverage to include individuals with a documented history of problematic hypoglycemia, even if not on insulin therapy.

This problematic hypoglycemia is defined as recurrent or persistent level 2 hypoglycemic events (glucose below 54 mg/dL) despite treatment modifications, or one level 3 hypoglycemic event requiring third-party assistance.

The patient or their caregiver must also receive sufficient training on the proper use of the CGM system, evidenced by the physician’s prescription. Prior to prescribing a CGM, the patient must have had an in-person or Medicare-approved telehealth visit for diabetes management within the preceding six months. For continuing coverage, follow-up visits with the healthcare provider are required at least every six months to assess the CGM regimen and overall diabetes treatment plan.

Covered Continuous Glucose Monitoring Systems

Continuous Glucose Monitors (CGMs) are classified under Medicare Part B’s Durable Medical Equipment (DME) benefit. This classification means that covered devices must meet specific criteria, including being able to withstand repeated use, having an expected lifetime of at least three years, and being used for a medical purpose.

Medicare primarily covers “therapeutic” CGMs, which are devices approved by the Food and Drug Administration (FDA) for use in making diabetes treatment decisions without requiring confirmation from a traditional blood glucose meter. A complete CGM system typically includes a receiver or monitor, a transmitter, and disposable sensors, all covered under Medicare Part B as part of the DME benefit if the system meets FDA approval for therapeutic use and other Medicare requirements.

While some CGM systems can display data on smartphones or other personal devices, Medicare requires the use of a stand-alone receiver or an integrated insulin pump classified as DME to display glucose data for coverage. The disposable sensors and transmitters, which require regular replacement, are considered covered supplies necessary for the functioning of the durable portion of the CGM system.

Steps to Obtain Medicare Part B Coverage

Securing Medicare Part B coverage for a Continuous Glucose Monitor involves several procedural steps, beginning with the treating physician. The physician plays a central role by providing a written order or prescription for a therapeutic CGM. This prescription must include specific details, such as the exact CGM device, the quantity and frequency of sensors and supplies, and confirmation that the CGM is medically necessary for diabetes management.

The physician must also ensure medical records document the beneficiary’s diagnosis, insulin treatment, and how the CGM will manage their diabetes. After the prescription is issued, beneficiaries should work with a Medicare-enrolled Durable Medical Equipment (DME) supplier.

These suppliers are responsible for verifying Medicare coverage, collecting the prescription, and handling the necessary paperwork for claim submission to Medicare Part B. The DME supplier typically submits the claim to Medicare Part B on behalf of the beneficiary using the appropriate claim form.

After submission, processing times can vary, and Medicare may request additional information to support the claim. Beneficiaries will be notified of the approval or denial of their claim.

Beneficiaries are responsible for certain financial obligations under Medicare Part B. After meeting the annual Part B deductible, which is $240 in 2024, individuals typically pay 20% of the Medicare-approved amount for the CGM and its supplies. Medicare covers the remaining 80% of the cost.

If a claim for CGM coverage is denied, beneficiaries have the right to appeal the decision through a multi-level process. The initial appeal, known as a redetermination, is typically followed by a reconsideration by an independent review entity (Maximus for DME appeals) if the first appeal is unsuccessful.