Continuous BG monitoring medicare coverage


#1

My A1c numbers are below 6.8. Although I take long acting insulin twice a day (3-4 units twice a day), I suspect I will be denied the insurance coverage for CGM. I am covered by medicare.
I do not want to wait till my diabetes worsens to qualify for coverage. Any suggestion as to how I can qualify or if there is any body who is covered by Medicare in my situation. I test twice a day and there are no documented complications due to diabetes. thanks


#2

Hi Kumar2:
No, you will not qualify for coverage under Medicare, however, you may not need much of a change to do so. Medicare requires you to be doing 3 or more injections per day and testing 4 or more times a day. They are very strict on reviewing doctor’s notes within every 180 day period and if you fail the requirements under the doctor’s notes, you are not covered. The rules are as follows and I have also included the Dexcom Medicare link:

  • The beneficiary requires a therapeutic CGM. The beneficiary has diabetes mellitus; and,
  • The beneficiary has been using a home blood glucose monitor (BGM) and performing frequent (four or more times a day) BGM testing; and,
  • The beneficiary is insulin-treated with 3 or more daily injections (MDI) of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and,
  • The beneficiary’s insulin treatment regimen requires frequent adjustments by the beneficiary on the basis of therapeutic CGM testing results.
  • Within six (6) months prior to ordering the CGM, the beneficiary had an in-person visit with the treating practitioner to evaluate their diabetes control and determine that the above criteria are met; and,
  • Every six (6) months following the initial prescription of the CGM, the beneficiary has an in-person visit with the treating practitioner to assess adherence to their CGM regimen and diabetes treatment plan.
    Medicare Dexcom Requirements

#4

I’m sorry. I hate to contradict someone, but c-peptide is not a requirement for CGM coverage. CGM is open to both T1 and T2’s who use insulin as described by CJ114.

Pump coverage, however, does require either the presence of of antibodies or a c-peptide under a certain number.


#6

I looked back over my lab tests and I got the c-peptide in 2015, so that was before I signed up to get Medicare coverage for the G5–it had to have been a requirement for my pump supplies, instead.


#7

I am new to Medicare and had to have a Fasting Glucose, C-Peptide and A1C tests. These are what I have been told are the needed test results Medicare uses for evaluation. 223mg/dL, <0.10ng/mL and 6.7% respectively. Then a prescription with the doctors signature and noted on the prescription that the prescription is a “Medical Necessity”. I am receiving insulin for my pump through my Druggist. I am going to order Dexcom Sensors from a Dexcom Representative tomorrow. I attempted to order directly from Dexcom and was refused. I was told by Dexcom the representative would call me in “a few days”. It has been a week and two days since. I hope this and the other past responses and future responses help.