Criteria for Medicare coverage of CGM announced

Diabetes Technology Glucose Monitoring
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http://investor.shareholder.com/dexcom/releaseDetail.cfm?ReleaseID=1018683

NOTE: To read the criteria in full, slide to the right.

March 24, 2017
Medicare Announces Criteria Covering Dexcom G5 Mobile CGM for All People with Diabetes on Intensive Insulin Therapy

SAN DIEGO–(BUSINESS WIRE)-- DexCom, Inc. (NASDAQ:DXCM), the leader in continuous glucose monitoring (CGM) for people with diabetes, is pleased to announce that the U.S. Centers for Medicare & Medicaid Services (CMS) has published an article clarifying criteria for coverage and coding of the Dexcom G5 Mobile system, the only therapeutic CGM under this CMS classification. People covered by Medicare who have either Type 1 or Type 2 diabetes and intensively manage their insulin will now be able to obtain reimbursement.

“This is a new era and a huge win for people with diabetes on Medicare who can benefit from therapeutic CGM,” said Kevin Sayer, President and Chief Executive Officer, Dexcom. “This decision supports the emerging consensus that CGM is the standard of care for any patient on intensive insulin therapy, regardless of age.”

According to CMS, therapeutic CGM may be covered by Medicare when all of the following criteria are met:

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 multiple daily injections (MDI) of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and,
The patient's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of therapeutic CGM testing results.

In order to be included in this category, the system must be defined as therapeutic CGM, meaning you can make treatment decisions using the device. Dexcom G5 Mobile is the only system approved by the FDA to meet that criteria.

See the Medicare Administrative Contractor (MAC) website for instructions for individual claim adjudication. Coverage is effective for claims with dates of service on or after January 12, 2017. A link to the article on coding and coverage can be found at: https://med.noridianmedicare.com/web/jddme/policies/dmd-articles/coding-and-coverage-therapeutic-continuous-glucose-monitors.

To learn more about CGM, visit www.dexcom.com.

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This sounds incredibly sane for any government agency, let alone CMS! Let’s see how they put it into practice…

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Some of the four criteria above were unfortunately cut off. Here they are as published on this Dexcom website:

  • 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 multiple daily injections (MDI) of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and,
  • The patient’s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of therapeutic CGM testing results.

This is good news!

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Thank you Terry4. It actually slides to the right on my phone. I edited the post.

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Sorry, I didn’t think to click on the quoted text and use the slider. Old dog and new tricks …

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Does anyone know how this is required to have gone on? I’ve been economizing on strips lately because they’re so bloody expensive.

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I don’t know the answer to that question, but now you know what you need to document to satisfy Medicare eligibility for CGM. I think using the memory of a BG meter is the easiest way to do this but we’ll need to find out what Medicare actually wants. In the past I’ve read that Medicare accepted hand written logs. I’ve never been asked to produce any evidence of strip usage.

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Not really. I haven’t been using 4 strips every day for the reason given above. So if they really do require documentary proof, I can’t provide it. If they don’t, then great. What I’m hoping is that they’ll accept the doctor’s word, but that is not a safe assumption with these folks.

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I have had good luck w this. It’s a pain to document but well worth it. I didn’t say this but sometimes “fudging” does happen if necessary. But. I think maybe requirements will change now that we can actually bolus corrections and meals a la cgm reading. It’s marvelous when my cgm is being accurate enough to do that, which is most of the week.

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What I’m really wondering more than anything else is, how far back they want the records to go. Days? Weeks? Months?

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Relative newbie here, so perhaps I’m overlooking something. I thought if you were under Medicare, your strips were covered. That’s certainly the case for me. But if I weren’t covered and money was tight, I would certainly purchase some of the lower cost strips that are available. I have purchased Walmart’s Relion Prime strips at 18 cents each. I don’t think they are the best of the best, but they’re not bad either, I’ve run tests against the more expensive strips and I’m not concerned about using them, if needed. And I’m reading on the forum that other low-cost brands are out there too.

It would seem to me that supplementing your strips with these low-cost alternatives for a few months to pass the test is feasible?

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I haven’t been on Medicare very long and I’m used to buying the strips directly without a prescription for reasons that take too long to explain here. Believe it or not, it was the lowest cost option.

However, I think you’re right about Medicare coverage so I intend to get a scrip from the doctor and see what happens. You’re not the first to point this out. Anyway, my preferred practice, quite aside from any CGM issues, is to test 6 to 8 times on an average day. So I do need to pursue this regardless of other considerations.

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David - I tried looking for actual documentation but struck out. I remember some member posts here (possibly @Zoe) over the years talking about supplying a recent 30-day record to justify more than the normal anemic Medicare allotment. I think Medicare covered 100 strips for 30 days for T1Ds and 90 days for T2Ds unless an exception was provided. I also think hand-written logs were accepted.

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Hi all

Hope everyone is doing well! I can’t speak to the CGM/Medicare issue as I don’t have (or want) one, but Terry is right that it was me that talked about the required log. When I first got on Medicare they asked me to provide that log and yes, it was hand-written. They sent me a form for the log and I transferred all my numbers to the form. I seem to remember having to do it twice. At the time I assumed it was a log that would be required periodically ongoing, but I haven’t been asked to do it again. (I’ve been on Medicare for 3 1/2 years now). I was told that the idea was to "demonstrate" that I did, in fact, utilize the number I was using which was 10 per day. I did that and have had no trouble getting that 10 a day ever since. (Which, with my CalPers supplement is now totally free of charge…unless I have a deductible which CVS won’t bill for, but that is a whole other story!).

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This reminds me of the old we-won’t-make-you-a-loan-unless-you-can-prove-you-don’t-need-it-in-the-first-place. If Medicare would pay for the strips, I could test as often as I should. If I tested as often as I should, I could get Medicare to pay for the strips.

Sigh.

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Today, my dear wife applied for the new Dexcom G5 CGM that was approved by Medicare on 3/24/17. Now we are waiting for the local Dexcom Sales Rep to contact us to start the paperwork process with Medicare. My wife saw her Endo doctor yesterday who promptly wrote her a script, and letter of necessity for the G5. We are both very happy that after many years this is finally coming to fruition after losing ALL four of our appeals on the OmniPod pods to be covered by Medicare. If the Medicare Admins ever saw how a diabetic suffers during an episode of low BG then they should never question the use of a CGM as an excellent life saving device.

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Good luck, @Jimbo31! There are many here, including me, following how this all goes. Please keep us posted.

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Thanks Terry, I’ll be sure to keep everyone posted regarding our experience process with Medicare.

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Yes, please. I am keenly interested in how this plays out.

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There was a Dex rep in my Endo’s office the other day. She was joyfully telling the whole office about the news of Medicare covering their G5. If you’re on Medicare, Liberty Medical is exclusively handling all of the orders for Medicare patients to receive the Dexcom G5. From what she told me on Friday, Liberty is already taking orders and sending them out to customers. I can’t verify this information because I’m not on Medicare or have any experience with Liberty Medical.