Does Medicare Cover CGM If Not on Insulin?
Clarify Medicare's specific Continuous Glucose Monitor (CGM) coverage rules for non-insulin users, including eligibility and process.
A Continuous Glucose Monitor (CGM) tracks glucose levels throughout the day and night, offering insights into how diet, exercise, and medication affect blood sugar. Unlike traditional blood glucose meters, CGMs provide real-time data, helping individuals and their healthcare providers make informed decisions about diabetes management. Understanding Medicare’s coverage policies for these devices is important, especially for those who manage diabetes without insulin, to determine eligibility and navigate the process of obtaining a CGM.
Medicare’s General CGM Coverage
Medicare Part B, which covers medical services and supplies, includes Continuous Glucose Monitors under its Durable Medical Equipment (DME) benefit. DME refers to equipment that serves a medical purpose, can withstand repeated use, and is suitable for use in the home. For a CGM to be covered, it must be prescribed by a Medicare-enrolled doctor or healthcare provider who deems it medically necessary.
A CGM system typically includes a receiver, disposable sensors, and a transmitter. Medicare considers CGMs as DME if they have a stand-alone receiver to display glucose data, even if a smartphone app is also used. The device must also be approved by the Food and Drug Administration (FDA) and prescribed in accordance with its indications for use.
Specific Coverage Criteria for Non-Insulin Users
Medicare has expanded its coverage criteria for CGMs, making them accessible to individuals with diabetes who do not use insulin but meet specific conditions. To qualify, a beneficiary must have a diagnosis of diabetes mellitus, including both Type 1 and Type 2 diabetes.
A primary criterion for non-insulin users is a documented history of problematic hypoglycemia. This is defined as recurrent (more than one) Level 2 hypoglycemic events (glucose levels below 54 mg/dL) that persist despite attempts to adjust medication or modify the diabetes treatment plan. Alternatively, a history of one Level 3 hypoglycemic event, characterized by altered mental or physical states requiring third-party assistance, can also establish eligibility. The prescribing physician must assess that the CGM will help improve glycemic control and that the individual requires adjustments to their treatment regimen based on glucose results.
The medical record must reflect that the patient has been seen for diabetes management within six months prior to the CGM prescription, either in-person or via Medicare-approved telehealth. This documentation confirms the ongoing medical necessity. The patient or their caregiver must also demonstrate sufficient training in using the prescribed CGM system.
Obtaining Your CGM Through Medicare
Once a beneficiary meets the specific coverage criteria, obtaining a CGM involves several steps, primarily coordinated through the healthcare provider and a supplier. The first step requires the patient’s healthcare provider to issue a prescription or order for the CGM system, confirming its medical necessity.
Detailed medical records supporting the coverage criteria, especially documentation of problematic hypoglycemia for non-insulin users, must be compiled by the provider. This includes chart notes reflecting the patient’s diabetes diagnosis, history of hypoglycemic events, and the rationale for prescribing the CGM to improve glycemic control. The prescription and supporting documentation are then submitted to a Medicare-approved Durable Medical Equipment (DME) supplier. This supplier handles the claim with Medicare; ensure they participate with Medicare and accept assignment to avoid unexpected costs.
Costs and Maintaining Coverage
Even with Medicare coverage, beneficiaries are responsible for a portion of the CGM system’s cost. Continuous Glucose Monitors are covered under Medicare Part B, which means that after meeting the annual Part B deductible, Medicare generally pays 80% of the Medicare-approved amount. The beneficiary is then responsible for the remaining 20% coinsurance. For 2025, the Part B deductible is $257.
Medicare Advantage Plans (Part C) must cover everything Original Medicare covers, but they may have different cost-sharing structures, including varying deductibles, copayments, and coinsurance amounts. Beneficiaries with these plans should contact their specific plan to understand their out-of-pocket costs. To maintain ongoing Medicare coverage for a CGM, regular follow-up appointments with the prescribing physician are necessary. These visits, which can be in-person or via Medicare-approved telehealth, must occur at least every six months. During these appointments, the physician must document that the patient continues to meet the coverage criteria and adheres to their diabetes treatment regimen.