Criteria for Medicare coverage of CGM announced


#21

Jason,

What you said about Liberty Medical handling all the orders for Medicare is exactly the same thing as what I was told last week by a Customer Service Rep at Dexcom. The CS Rep further stated that Dexcom is still awaiting final approval of their contract from Medicare which is expected by mid-April. (From past experience, CMS moves VERY slowly) However, today when we saw the diabetes educator at our local hospital who teaches people how to use the Dexcom, and also starts the paper work ball moving forward informed us. Once the local Dexcom Sales Rep has received the faxed approval paperwork from my wife’s Endo, we were told that the Dexcom Sales Rep then takes care of the ordering, and the billing paperwork for the Dex 5, along with having it shipped to my wife. We are now awaiting a call from the local Sales Rep to see what our next step is in this process. I don’t know what hoops others who have received a Dexcom CGM had to jump through to receive one?


#22

Me as well…will be on Medicare the end of this year/beginning of next…currently on a pump w/o cgm.


#23

Here is the latest info we received regarding the Dexcom G5 via email from the Dexcom Sales Rep:

"I apologize, but as you can imagine we have had thousands of Medicare patients apply for the Dexcom in the past 2 weeks. That being said it’s taking longer than usual to process all the orders.

All of our Medicare patients have been sent directly to Liberty Medical and they are working to process those orders ASAP.

Please be patient as you should hear from Liberty in the next couple weeks.

If you don’t hear anything in 2 weeks please feel free to reach out to me and I will look into it. Regards, Mark"

IMHO; This reminds me of just like being in the military again, it’s called “hurry-up and wait!”


#24

One more data point to add to this discussion - I’ve been contacted by Liberty, via email, and told my medical order is in place and they are simply waiting on my insurance to approve. They will contact me when they have heard back. My insurance is Medicare as primary.

I’m a 66 year old T1 who tests 6-8 times a day. I had a Dexcom G4 but lost coverage the month I turned 65. Although I can document a few hypoglycemic episodes a month, without awareness, it seems the approval really spins around using the G5 for treatment decisions and a history of doings lots of glucometer testing.

I’ll add to the discussion when I know more. But I think this is where I cross my fingers and toes.


#25

From Www.libertymedical.com/CGM

Medicare currently has 4 requirements for CHM approval:
1 - patient must be Diabetic
2 - patient must be injecting insulin
3 - patient must test at least 4 times a day and needs to submit 30 day blood glucose logs (BGL)
4 - patient must supply Medical Records from within the last six months

In addition to the initial phone interview with Liberty for name, address, insurance, etc. I sent the following to meet these requirements:

  • a one month report from my Animas Vibe meter remote via Diasend. That included BG values that I entered manually from my G4 when bolusing for meals and high BG’s plus those from actual test strips. I was able to scan and email that report to Libert Medical.
  • a 6 month medical report from my doctor. Liberty requested this but I followed up with an email to the Endo’s office to clarify why Liberty needed it.
  • an ABN form or Advanced Beneficiary of Notice of Noncoverage where I chose option 1, meaning I want them to ship as soon as I meet the 4 requirements and will pay for the G5 if for some reason Medicare and/or my supplement does not. The other option 2 is you will not pay but will wait until Medicare approves and then have them ship the G5.

The process started March 29 with the phone interview and should end next Wednesday, April 12 when I am scheduled to receive my G5 initial 3 month shipment. :+1::+1::+1::+1::grinning::grinning::grinning::grinning: Hurray!!! No more paying $304/month!!! What will I do with that extra money? Why, go to Disney World, what else? ( note: we live 13 miles from their main gate so I really will save most of it​:smirk:)

PS: there is a phone number to call just for the Medicare CGM folks: 1-888-560-4005.

Good luck to everyone!


#26

It sounds like you are self-funding your Dexcom at this point so your decision makes sense. I, on the other hand, am a skeptic with trust issues, and a fan of reading the fine print. So I’m going Option 1. I dont think it’s a strech to assume this will follow Medicare’s usual 80/20 coverage split but I’d like to know, for certain, before signing a contract. Does the ABN state what would be owed if the claim denied?


#27

I don’t want to discourage anyone. That said though, about three weeks ago I tried to connect with Liberty for Dexcom CGM and stopped trying after being on hold for hours. Maybe they are being inundated w interest and this will get better over time. A day later a Liberty rep called me back and said they weren’t yet on board but the process was in play…best of luck to all of us!


#28

I have not verified this, so take with an appropriate amount of salt.

I have been given to understand that if Medicare approves a CGM, it and its supplies are treated as DME and covered fully, in much the same way as a pump.


#29

I know insulin pumps including their supplies, insulin, and test strips are all covered under Medicare Part B. I know Part B has a relatively low annual deductible. I had thought even Part B was an 80/20 split but I have received pump supplies with no co-pay. I did co-pay for Part B strips at Walgreens, however.

Part of the approval logic that Medicare had to satisfy to approve payment for the Dexcom G5 was that at least one component of the kit had to be designated as "durable medical equipment’. It needed to be expected to last at least three years. The Dexcom receiver was given this designation and made the CGM sensors and transmitters eligible for coverage since it’s part of the system.


#30

There is an issue that I have not seen mentioned. In order for Medicare to cover the Dexcom G5, the CGMS is to be used, INSTEAD of the blood testing meter to determine changes in insulin, diet, etc… After using the G5 since it came out, we have found it is often not as accurate as a blood test. Often it is 20-50 points off and sometimes much higher. Since the G5 needs to be calibrated twice in 24 hours, Medicare will cover a blood test meter and a small amount of strips. The CGMS is great for showing possible lows or highs, especially for people who no longer feel the symptoms until you crash. We have been looking for a place at Medicare to write to explain this issue of accuracy.


#31

The G5’s instructions say to calibrate twice a day and to also test with a finger stick in various situations:

  • If you have symptoms that don’t match the CGM value, e.g. dex says 150 but you feel low
  • When you are taking Tylenol
  • When you don’t trust the sensor, such as on the first day
  • When the signal has been interrupted

I would hope that they would allow more than 2 strips a day, since those are the instructions.


#32

While Medicare has long maintained a coverage policy for a default number of glucose test strips (too few, in my opinion) based on diabetes type, they have always been willing to entertain appeals for a greater quantity. I’m assuming that Medicare will administer their test strip limits, and issue exceptions, as they did prior to CGM coverage. I could be wrong and we’ll soon know.


#33

I went back to a pump supply order that was placed in October, 2016, so that any totals wouldn’t be subject to a deductible. And it looks like Medicare Part B covered 80% of the Medicare approved amount. (see attached photo) Now, this was then forwarded on to my supplemental BCBS policy which picks up the 20% not covered by Medicare. So, no charge for specific items, just the yearly Medicare deductible and a monthly benifits premium for the BCBS though my employer, UofM. I wouldn’t be surprised to find a Dexcom G5 is also covered 80/20. When I first went on a pump I was part of the working class so, not on Medicare. Can’t report on how they would have handled the initial hardware.


#34

On April 5th my endocrinologist enthusiastically faxed a Rx to Dexcom in hopes of my getting one through Medicare. The office explained this was the first such application they made and were unsure of what info they needed, but, onward! Yesterday I called Dexcom to see if they had received any documentation. They had and it had gone to Liberty just hours before. I called Liberty and they said to give it 24-72 hours before expecting to hear anything back. But he did say that as of April 15th they’d been given the okay to ship Dexcom G5 units that would be covered by Medicare insurance. He then listed the criteria. Now, I’m going from memory here. I wish I’d taken notes.

  1. Patient must be diabetic.
  2. Must be on insulin therapy.
  3. Must be able to prove they tested blood glucose a minimum of 4 times a day over the last 60 days and made treatment decisions based on the results. My doctor’s office would be asked for this from any meter downloads they have on record. He was unsure how it would go with manual logbooks and user supplied data.
  4. An appointment within the last 4 months with the doctor managing the patient’s diabetes.
  5. A recent A1c result.
  6. A c-peptide result.
  7. A copy of medical records covering the last six months.

Now, I’m not sure if all these boxes need to be checked to be approved. I guess I’ll know more when they call back for my insurance information. The suggested timeline from insurance application to Dexcom in hand is between 1-2 weeks at this point. Since I have Medicare and a supplemental BCBS maybe it will take longer? And Medicare coverage will indeed follow the usual 80/20 split. I’ll update again when I know more.


#35

Actually these seem to be a mismatch with the CMS ruling and Dexcom interpretation. You should not need 4-7.


#36

Right. The initial announcement didn’t list the specific documentation that would be required just the broad strokes. Again, I have no idea how important some of this will be toward Medicare coverage. The one thing that wasn’t mentioned specifically is hypoglycemic episodes. That used to be a huge part of any coverage determinations. Maybe they are going to glean that info from the logs? Or maybe that’s not as important as it used to be. Dunno.


#37

Actually if you read the CMS decision it was really about the FDA approval that you could make insulin adjustments based on the CGM. And CMS therefor concludes that the CGM can be used instead of fingersticks.


#38

Yes, I’m aware. I’ve been following this issue pretty closely. I had a Dexcom G4 Share but I lost coverage when I turned 65, almost two years ago. So, I have a keen interest in this process. :wink: What I have noticed is that with every report that comes out from folks talking to Dexcom/Liberty reps there seems to be discrepencies in the story. So, until lots of folks have worked their way though the Medicare approval process and have them in hand, it’s all just beta.


#39

Hi Mary,

My patience with the folks at Dexcom/Liberty is starting to run quite thin. We are now going on three weeks waiting for some sort of action from either of these two outfits, and haven’t heard not a thing? If Liberty Medical can’t keep up with the thousands of Medicare orders as they are claiming they are trying to fill since the Dexcom G5 was approved. So if Dexcom doesn’t want a lot of unhappy customers then their executives should have thought about having more than one sole source supplier to sell their CGM devices. I myself don’t buy into this sole source contractor bit in being able to deal exclusively with CMS. Sounds like collusion to me? CMS should allow diabetic patients to purchase these devices on their own with whom ever they choose to negotiate with. After all, this is the USA and customers should be able to buy medical products from who ever they want, and then CMS should reimburse the patient 80% of the final cost as they are required to by law. Seems to me that contractors like Liberty Medical are getting some nice kick-backs because of some powerful Washington lobbyists. JMHO!


#40

Yep. I feel your frustration. Today I was contacted by Liberty, missed the call, and decided to call back to see what was up. Big mistake. 65 minutes on hold (I was reading a good book) before it was my turn to talk to someone. I was then told they haven’t received anything from Dexcom or my doctor. Nada. But they’d be happy to setup an account and start the process. I so feel for my endo’s staff and all the work they have put into this. Liberty then sent me the authorization form to fill out AGAIN and it’s a very different form from the initial authorization I completed. But, okay. And they wanted blood glucose logs, again. And how do we get in touch with your doctor for a prescription?

So, I’m backing off and letting the chaos settle.