Is Continuous Glucose Monitoring Covered by Medicare?

Continuous Glucose Monitoring (CGM) systems offer a significant advancement for individuals managing diabetes by providing real-time glucose readings. These wearable devices continuously track blood sugar levels, offering a more comprehensive picture than traditional fingerstick tests and empowering informed decisions on diet, exercise, and medication. Medicare offers coverage for CGM systems, significantly reducing the financial burden for many seniors and individuals with disabilities. This article outlines the specific criteria for Medicare coverage, the types of systems included, the process for obtaining coverage, and the associated financial responsibilities.

Medicare Coverage Criteria for CGM

Continuous Glucose Monitoring systems are covered under Medicare Part B, categorized as Durable Medical Equipment (DME). To qualify, individuals must meet specific medical and usage criteria. A diabetes diagnosis is required. Furthermore, the individual must either be treated with insulin or have a documented history of problematic hypoglycemia. Problematic hypoglycemia is defined by specific criteria, including recurrent low glucose events requiring third-party assistance or classified as severe by a practitioner.

The CGM must be prescribed to improve glycemic control and be used in accordance with its Food and Drug Administration (FDA) indications for use. The treating practitioner must conclude that the beneficiary, or their caregiver, has sufficient training to use the prescribed CGM system. Regular follow-up is also required to maintain ongoing eligibility for coverage.

Beneficiaries must have an in-person or Medicare-approved telehealth visit with their treating practitioner within six months before the initial CGM prescription. During this visit, the practitioner evaluates the patient’s diabetes control and confirms that all necessary criteria are met. For continued coverage, these follow-up visits must occur at least every six months to assess the CGM regimen and the overall diabetes treatment plan.

Covered CGM Systems and Supplies

Medicare generally covers therapeutic Continuous Glucose Monitoring systems, which are designed to provide real-time data for making treatment decisions. For a CGM system to be covered, Medicare requires it to include a stand-alone receiver or integrate with an insulin infusion pump classified as Durable Medical Equipment (DME) to display glucose data. While a compatible smartphone or similar personal device can be used in conjunction with a dedicated CGM receiver, the receiver must be utilized at least some of the time for Medicare coverage to apply.

Several FDA-cleared CGM systems from various manufacturers are typically covered by Medicare, including devices from Abbott (such as FreeStyle Libre models), Dexcom (like the G6 and G7), and Ascensia (Eversense). Medtronic also offers systems that integrate CGM with an insulin pump, which can be covered for eligible beneficiaries. The primary components covered by Medicare include the CGM device or transmitter and the disposable sensors. Sensors typically have a limited lifespan, often lasting between 10 to 14 days, and require regular replacement.

Medicare covers the scheduled replacement of these sensors, along with any necessary accessories. Beneficiaries should confirm specific device coverage with Medicare or their chosen supplier, as approved models can be updated.

Steps to Obtain CGM Coverage

Obtaining Medicare coverage for a Continuous Glucose Monitor involves a structured process that begins with a thorough physician consultation. The treating physician plays a central role by evaluating the patient’s medical necessity for a CGM based on the established criteria. This consultation must result in a detailed prescription and supporting documentation confirming the diagnosis of diabetes, the use of insulin or history of problematic hypoglycemia, and a treatment plan. The prescription should specify the type of CGM device, the quantity, and the frequency of sensor replacement, along with a clear statement of medical necessity.

Once the physician has provided the necessary documentation, the next step involves identifying a Durable Medical Equipment (DME) supplier that is enrolled in Medicare. These suppliers are specifically authorized to provide medical equipment and process claims through Medicare. Beneficiaries can verify a supplier’s Medicare enrollment status to ensure their services will be covered. If a CGM or its supplies are obtained from a supplier not enrolled with Medicare, the beneficiary may be responsible for the full cost.

After selecting an approved DME supplier, the supplier will typically handle the submission of all required documentation to Medicare on behalf of the beneficiary. This includes the physician’s prescription and medical records that substantiate the eligibility criteria. Upon approval, the supplier will arrange for the device and initial supplies to be delivered. Ongoing supplies, such as sensors, are then typically shipped directly to the beneficiary on a regular schedule, aligning with the prescribed replacement frequency. Continued coverage requires regular follow-up appointments with the treating physician, usually every six months, to assess the CGM’s effectiveness and ensure ongoing medical necessity.

Financial Aspects of CGM Coverage

Continuous Glucose Monitors are covered under Medicare Part B, which entails specific financial responsibilities for the beneficiary. Medicare Part B typically has an annual deductible that the beneficiary must meet before Medicare begins to pay its share. For 2025, the standard Medicare Part B annual deductible is $257. After this deductible has been satisfied, Medicare Part B generally pays 80% of the Medicare-approved amount for Durable Medical Equipment, including CGMs and their associated supplies.

This means that the beneficiary is responsible for the remaining 20% coinsurance of the Medicare-approved amount. For example, if the Medicare-approved amount for a CGM system and supplies is $300 per month, after the deductible is met, Medicare would pay $240, and the beneficiary would pay $60. This coinsurance applies to both the device and the ongoing supplies, such as sensors.

Medicare Advantage (Part C) plans also cover Continuous Glucose Monitors, and their coverage must be at least equivalent to what Original Medicare Part B provides. However, Medicare Advantage plans are offered by private insurance companies, and their cost-sharing structures, network restrictions, and additional benefits can vary significantly. Some plans may offer different deductibles, copayments, or coinsurance amounts than Original Medicare. Beneficiaries enrolled in a Medicare Advantage plan should review their specific plan details to understand their out-of-pocket costs and any network requirements for obtaining CGM systems.