Does Medicare Cover a Continuous Glucose Monitor?

Continuous Glucose Monitors (CGMs) are valuable tools for managing diabetes, offering real-time insights into blood sugar levels. They simplify diabetes management by providing continuous data, reducing the need for frequent fingerstick tests. Understanding Medicare coverage for these devices is important for beneficiaries. This article clarifies the conditions and procedures for obtaining Medicare coverage for a CGM.

Medicare Coverage Criteria

Continuous Glucose Monitors are covered under Medicare Part B as Durable Medical Equipment (DME). For coverage, a Medicare beneficiary must meet specific medical necessity criteria established by the Centers for Medicare & Medicaid Services (CMS). A diagnosis of diabetes (Type 1 or Type 2) is required. Beneficiaries must either be treated with insulin or have a documented history of problematic hypoglycemia. Problematic hypoglycemia includes more than one Level 2 hypoglycemic event (glucose less than 54 mg/dL) that persists despite attempts to adjust medication, or a single Level 3 hypoglycemic event (glucose less than 54 mg/dL) requiring third-party assistance.

The CGM must be prescribed in accordance with its Food and Drug Administration (FDA) indications for therapeutic use. A treating physician must determine the need for the CGM and provide a prescription. This requires a face-to-face visit (which can be via Medicare-approved telehealth) within six months prior to the order to evaluate the beneficiary’s diabetes control and confirm eligibility. The physician must also confirm the beneficiary or caregiver has received sufficient training to properly use the CGM. For ongoing coverage, beneficiaries must have a follow-up visit with their practitioner at least every six months to document continued adherence to their diabetes treatment and CGM use.

Types of Continuous Glucose Monitors Covered

Medicare covers both Real-Time Continuous Glucose Monitors (RT-CGM) and Intermittently Scanned Continuous Glucose Monitors (isCGM). These systems include a sensor, inserted under the skin, and a transmitter that sends data wirelessly. Coverage also encompasses necessary supplies like replacement sensors and transmitters. Covered devices must be FDA-cleared for therapeutic use, meaning they can be relied upon for diabetes treatment decisions, such as insulin dosing, without a confirmatory fingerstick blood glucose test.

A key requirement for Medicare coverage is that the CGM system must include a stand-alone receiver or integrate with an insulin infusion pump classified as Durable Medical Equipment (DME) to display glucose data. While many modern CGM systems offer smartphone applications, Medicare generally requires the use of the dedicated DME receiver at least some of the time. If a system exclusively relies on a smartphone or other non-DME device for displaying glucose data, it may not be covered, as it typically does not meet the definition of DME.

Obtaining a Continuous Glucose Monitor

The process of acquiring a CGM begins with the treating physician. The doctor must provide a prescription and a detailed written order, specifying the medical necessity of the CGM for the beneficiary. This order must accurately reflect the beneficiary’s diagnosis, insulin treatment status or history of problematic hypoglycemia, and the physician’s determination that the device will improve glycemic management. The physician’s notes from the required face-to-face or telehealth visit are integral to this documentation. Accurate and complete medical records are important for the Durable Medical Equipment (DME) supplier to verify eligibility and for Medicare to process claims.

Once medical documentation is in place, the beneficiary works with a Medicare-approved DME supplier. Suppliers verify Medicare eligibility and ensure the prescription aligns with coverage requirements. Beneficiaries can locate approved suppliers through Medicare’s online directories.

The CGM device and its associated supplies are typically shipped directly to the beneficiary’s home or made available for pick-up. Initial setup assistance and education on using the device are often provided by the supplier or healthcare team. Subsequent refills of sensors and transmitters follow a similar process through the same DME supplier, based on the physician’s ongoing orders and continued medical necessity.

Understanding Your Costs

Continuous Glucose Monitors (CGMs) are covered under Medicare Part B. After meeting the annual Part B deductible, beneficiaries are generally responsible for a 20% coinsurance of the Medicare-approved amount for the device and its supplies. It is important to ensure the medical equipment supplier accepts Medicare assignment, as this prevents them from charging more than the Medicare-approved amount.

For beneficiaries enrolled in a Medicare Advantage Plan (Part C), CGM coverage must be at least equivalent to Original Medicare. However, specific cost-sharing amounts (deductibles, copayments, coinsurance) vary significantly between plans. Beneficiaries with these plans should contact their plan administrator directly to understand their financial responsibilities. Medicare Part D does not cover CGM devices, as these are classified as durable medical equipment under Part B.

Supplemental insurance plans (Medigap policies) can help reduce out-of-pocket costs for beneficiaries with Original Medicare. Many Medigap plans cover the 20% coinsurance amount and the Part B deductible. Medicare Advantage plans often include an out-of-pocket maximum, which caps the total amount a beneficiary might pay for covered services in a given year. This maximum offers financial protection by limiting overall spending on medical care, including CGM costs.