Does Medicare Pay for a Continuous Glucose Monitor?

A continuous glucose monitor (CGM) is a compact wearable device that provides continuous, real-time data on glucose levels throughout the day and night. Unlike traditional fingerstick testing, CGMs offer insights into glucose trends and patterns, alerting users to high or low glucose events. This technology empowers individuals with diabetes to make more informed decisions about their diet, exercise, and medication management. The constant flow of information from a CGM can significantly enhance the proactive management of blood glucose, moving beyond snapshot readings to a more dynamic understanding of how the body responds to various factors.

Medicare Coverage Basics for CGMs

Medicare offers coverage for Continuous Glucose Monitors (CGMs). Generally, these devices and their components are covered under Medicare Part B as Durable Medical Equipment (DME). Part B assists with costs of medically necessary outpatient care, including certain medical equipment. The sensors and supplies used with the CGM system are also typically covered under Medicare Part B, as they are integral to the functioning of the DME.

For a CGM to be covered, it must be prescribed by a healthcare professional and be an FDA-approved device. Medicare covers several FDA-approved CGM systems, including specific models from Dexcom, Abbott FreeStyle Libre, and Medtronic. While the main device and sensors fall under Part B, some related supplies or specific insulin types might be covered under Medicare Part D. Understanding which part of Medicare covers each component is important for beneficiaries.

Eligibility Criteria and Medical Necessity

To qualify for Medicare coverage of a Continuous Glucose Monitor, a beneficiary must have a diagnosis of diabetes mellitus. Individuals must either be treated with insulin or have a documented history of problematic hypoglycemia. Problematic hypoglycemia is defined as recurrent Level 2 hypoglycemic events (glucose below 54 mg/dL) that persist despite medication adjustments, or a single Level 3 hypoglycemic event requiring third-party assistance.

The healthcare provider must conclude that the individual, or their caregiver, has received sufficient training in using the prescribed CGM. This training is often evidenced by the prescription itself. The CGM must also be prescribed in accordance with its FDA indications for use. A treating practitioner must conduct an in-person or Medicare-approved telehealth visit within six months prior to ordering the CGM to evaluate diabetes control and determine if the coverage criteria are met.

For continued coverage, Medicare requires follow-up visits with the treating practitioner at least every six months. During these visits, the practitioner must assess the CGM regimen and diabetes treatment plan, documenting continued medical necessity. While some CGMs can display data on smartphones, Medicare generally requires a dedicated receiver that is classified as Durable Medical Equipment (DME) for coverage to apply.

Obtaining a CGM Through Medicare

Once eligibility for Medicare coverage of a Continuous Glucose Monitor is established, the process involves several steps. The first requirement is a prescription or order from your doctor. This prescription serves as documentation of medical necessity and confirms that you or your caregiver have been properly trained in using the device. The healthcare provider will also ensure the CGM is prescribed according to its FDA indications.

For the CGM device, including the transmitter and receiver, beneficiaries must work with a Durable Medical Equipment (DME) supplier enrolled in Medicare. These suppliers are responsible for verifying your Medicare coverage and handling the necessary paperwork. Confirm that the chosen supplier accepts Medicare assignment for proper billing. While the device components are obtained through DME suppliers, the disposable sensors are generally covered under Medicare Part D and acquired through a pharmacy.

After the prescription and supplier verification are complete, the DME supplier will arrange for the delivery and setup of the CGM system. Some pharmacies may also be certified DME suppliers, streamlining the process for both the device and sensors. Ensuring all documentation is submitted correctly to the approved supplier is key to a smooth acquisition process.

Understanding Your Costs

When obtaining a Continuous Glucose Monitor through Original Medicare, beneficiaries can expect out-of-pocket expenses. The CGM device is covered under Medicare Part B as Durable Medical Equipment. You are responsible for the annual Part B deductible. For 2025, this deductible is $257. After meeting the deductible, Medicare Part B covers 80% of the Medicare-approved amount, leaving you responsible for the remaining 20% coinsurance.

For CGM sensors and other disposable supplies, generally covered under Medicare Part D, costs vary based on your specific prescription drug plan. These plans have their own deductibles, co-payments, or coinsurance amounts. There is no annual out-of-pocket maximum for Original Medicare Part B, so the 20% coinsurance could accumulate.

Medicare Advantage (Part C) plans offer an alternative to Original Medicare and must provide the same level of coverage for CGMs. Specific costs, including premiums, deductibles, and co-payments, can differ between Medicare Advantage plans. Many beneficiaries with Original Medicare enroll in a Medigap (Medicare Supplement Insurance) plan, which can help cover the 20% Part B coinsurance and other out-of-pocket expenses, reducing the financial burden of CGM use.