CGM Policy Change Effective 4/16/2023

Type 1 and LADA
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  • The new policy is that one only has to have been diagnosed with diabetes but who also has a history of problematic hypoglycemia.
  • The change in policy became effective on Sunday 4/16/2023.

This is for all CGM’s, Dexcom, Libre and Senseonics

Click on new policy above to read the article at cms.cov

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33822

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I’m lost. It’s stating what exactly? BG monitors for anyone using insulin but regarding CGM you need to demonstrate need for it by your medical pro confirming that? I turn 65 this fall…

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Yes, that is correct. To see the latest on what your medical professional will have to certify that you comply with, the easiest is to go to the Dexcom Medicare coverage page. That page is located:

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What about problematic hyperglycaemia?

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I think the fed’s Medicare answer to that one is to take insulin to control it and use a CGM to avoid problematic hypoglycemia.

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But don’t you have to HAVE problematic hypoglycaemia in order to qualify? I must be missing something here. Maybe I’m low . . better check!

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Yes, so you qualify and get a CGM to help you avoid chronic .problematic hypoglycemia in the future.

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Regarding that (#4) you only need to be using insulin (of any kind – long-acting Lantus, for instance).
This means that type 2s can qualify for Medicare coverage of CGMs.

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What I see and don’t like is (definition) “A non-adjunctive CGM can be used to make treatment decisions without the need for a stand-alone BGM to confirm testing results” then “Non-adjunctive CGM devices replace standard home BGMs and related supplies. Claims for a BGM and related supplies, billed in addition to a non-adjunctive CGM device and associated supply allowance, will be denied.”

Do any of us trust our CGMs completely, all the time? No need to answer.

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So far Medicare has decided you only need one BG device. Meter or CGM, I doubt they will change that. It’s a problem because how do you calibrate it without a BG meter and test strips? I’ve had my Dexcom off 90 points the next day. So someone does have to decide if they want to keep getting test strips or a CGM covered. I still use about 50 test strips a month with my Dexcom. Most of it is within the first 24 hours of starting or restarting one. And then I do “checks” off and on.

I have a feeling Dexcom got it first approved by saying it will save Medicare some money because they won’t need test strips anymore. Even though Dexcom had always said when in doubt check. They still say fingersticks may be needed for treatment decisions. So with what exactly? Plus we know the Dexcom can be pretty wonky that first 24 hours. Medicare seems happy to go with covering one blood testing method only.

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Medicare’s policy of paying only for a CGM or a meter and supplies is problematic, as several have pointed out. With a new sensor, I always calibrate with my meter. On rare occasions, the new sensor and my meter are close, but more often, I really do have to correct my new Dexcom sensor since it could be off from 50 to 100. I also use my meter, following Dexcom’s instructions, whenever the Dexcom reading does not feel right, and while not often, that sometimes happens durnig the first 24 hours of a new sensor. I end up using 10-15 test strips a month.

So I pay for those test strips myself. My solution would not suit most people – I have an older meter – One Touch Ultra 2. Test strips from One Touch are too expensive, but thankfully a 3rd party has had more affordable prices – Gen/Ultimate. I have bought in quantity – 250 strips – at a reasonable price before inflation hit (both Amazon and WalMart). I see both of those are out of stock and right now, suppliers with stock have higher prices, as much as US$ 0.75/strip. Not happy about that, but I am still willing to pay when my current supply runs out. And I am guessing prices will come down a bit in the future.

When I first used these 3rd party strips, I did a number of tests using both OT and Gen/Ultimate - I found the 3rd party strips to be just as accurate as those from OT.

Not a perfect solution, but it works for me.

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12

You might want to look at an Ascensia Contour next 0ne meter which is far more accurate than any of the one touch meter series and costs about $13 and the strips bought 70 at a time are $25.99 or just over 0.37/strip. Different bundles are available. This is the meter and test strip that was included with the Medicare Dexcom G5 meter and then the strips were eventually dropped when the G6 was introduced for Medicare

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13

Well, dang. Here’s the question I keep not finding an answer to. Maybe too specific to my situation, or maybe it’s in the info somewhere and I just don’t see it. But here goes:

I started on Medicare 1 yr ago, and it entailed switching my Dexcom supplies from pharmaceutical (yay) to DME (huh? ok, I guess). Which entailed getting the ever-popular Receiver, since that’s the “durable” part, that’s still sitting in its box unopened and unused. Again, whatevs. But as I understand it, that gadget is not compatible with the G7, meaning medicare will require me to get a new one? And does that mean that I can’t get the G7 under Medicare for the same five years it takes to be eligible for a new pump under DME??? Cuz they come out with new versions a LOT more often than that!

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…and to answer my own question:

I just got off a call with my DME supplier. This is the (reallllllly screwy) situation as it stands:

  1. Yes, I need a new receiver for Medicare to cover the G7 as DME
  2. No, I am not eligible for a new receiver for another 4 yrs, having received my current one exactly a year ago.
  3. Medicare will not cover G7 supplies unless I have a G7 receiver.
  4. But they won’t pay for it until 2027. At which point it will probably be a G12 or something.
  5. Supplier (Wellstart) says they will supply G7 sensors if I sign a waiver stating that I have purchased a receiver. Which they tell me I can get OTC for $70-90 or so. Or I can just lie, which I would never never never do (any more than I would risk eternal damnation by claiming I have only 10 days of supplies remaining when I re-order, even though I really might actually y’know… have a few extra. I would never do that. Honest).

In other words, I have to buy the DME part myself, out of pocket, in order for Medicare to cover the non-DME part… AS DME!!!

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Tandem X2 pump is also a considered a receiver, but still pending upgrade to support G7.

Not sure if MC sees it that way.

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Good point—hadn’t thought of that b/c I wasn’t on the Tandem when I started on Medicare. So I hadda get a receiver (that I never got out of its box). I asked my DME supplier if the Tandem would count as a receiver for the G7, and they said no because it’s not compatible with the G7 yet. Well duh. But when it is compatible, I asked? “Can’t answer that. I can only say that it doesn’t qualify now.” Yeesh. Still, I think it’s reasonable to assume that if it qualifies for the G6 it will count for the G7 too.

Whole system was designed by Rube Goldberg. In his sleep.

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Thanks for posting about your MC experience, I have another year before all that fun. I think my Tandem will be oow just prior to MC start.

I think a MC “purchased” pump gets a 5 year “warranty”??

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Even RG systems have a certain logic and rational flow. This? I dunno…

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Yup, as opposed to 4 yrs from the manufacturer. One reason I switched to Tandem is remote updates, because I’m not getting a new pump any time soon.

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Quick follow up: I called Dexcom and they informed me that the Tandem:X2 will count as a receiver for the purposes of Medicare eligibility. So no issue for me to upgrade when the time comes. Yay.

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