Medicare and CGM Coverage

I have been experiencing low blood sugar episodes and not always feeling them. Many older type 1 people have this problem. This would not be so much of a problem if Medicare would cover CGM’s. I have not been able to use a CGM for three years. I had a 48 two nights ago, and did not feel it. A CGM would have helped so much. Many long term type 1 people have the same problem.
JDRF Advocacy is working hard to get Medicare coverage of CGMs. Please click on this link to send a prepopulated email to your Members of Congress asking them to co-sponsor this legislation!!! Click on “Take Action.”

http://advocacy.jdrf.org/

1 Like

i haven’t been following this closely because 1) I’m a long way from Medicare, and 2) I’m not interested in a cgm, but at a glance I think the problem is that their is limited data showing that cgm reduces prevalence of SEVERE hypoglycemia… People passing out, wrecking cars, falling off of cliffs, etc… That’s not to say that they don’t, I just haven’t been made aware of a lot of data to support it…

Outside our own circles when someone hears “I had a 48 and didn’t feel it” they think “well, you had a low blood sugar, you figured it out and treated it appropriately, what’s the problem? That goes to illustrate that their is no problem at all”

CGM use has become widespread during or after the vastly superior analog insulins, pumps, and intensive home glucose testing— all of those things tremendously reduced the prevalence of cases of severe hypoglycemia— which makes the necessity of cgm harder to illustrate…

To me, the bottom line should be that if a doctor says it is necessary no insurer should be able to say otherwise, whether private or public (Medicare). But I do think we will have an uphill battle to prove to others that a cgm is a medical necessity…

@Sam19, the problem is that even if a doctor says a CGM is a medical necessity; even if a senior goes through all the appeals processes and WINS the appeal, Medicare interprets the current law as saying it cannot be provided.

Today, seniors are being placed into a second class of citizenship because they made it to Medicare. If you hope to make it to Medicare one day, wouldn’t it be better if it were ready to help you when you needed it?

2 Likes

I agree completely that I’d like Medicare to cover them, I’m just pointing out some of the things that are making it more difficult to illustrate the necessity… If anything I think the argument is stronger that they are necessary for seniors and young children than anyone else…

lots of people are taking a look at this from a cost savings basis. a CGM is less expensive than trips to the ER.

the bottom line for me is that NO ONE should decide what I need to take care of my health. Especially the government.

Sarah :four_leaf_clover:

I agree completely-- unfortunately the system involves insurance paying for others treatments as the standard way of doing business. It’s a system horribly flawed by design. I think the real road to progress is figuring out ways to reduce prices enough that most can afford the things they need out of pocket, and have resources available for those who can’t… As long as we keep operating with the assumption that everything has to be so expensive that most need insurance to cover it… We can never really get ahead.

that’s an argument I wouldn’t personally be able to claim. :slight_smile: In all the years I’ve been diabetic I ended up in the ER just once back in the early 80’s, following paramedics coming to the house AFTER I had self-injected glucagon following an accidental large insulin injection into a vein in my leg. I was trying to be discreet at a restaurant, so I injected into my calf under the table. when I pulled the needle out, the syringe was full of blood and my bg’s started plummeting within a few seconds. Long story short, the glucagon got my bg’s up in short order, so when I was loaded into the ambulance I was already high and nauseous. The ER did nothing for me. a waste of time, but understandable, given the circumstances.

I hope not to visit an ER for any reason. :slight_smile:

I’ve never been in the er for diabetes, but I think it’s not the usual case.

1 Like

Excellent reply, YogaO. Thanks!

Sam, there are many CGM’s approved after documentation is submitted showing the BG’s for a months or so. If there are many bad hypos, many insurance companies will then approve a CGM. The endo must also submit a letter of medical necessity. Medicare does not follow that path.

I’ve been twice, before the pump, but I had a recent low that were it not for the CGM, I might have made another early morning visit (if I was lucky).

One of the people who testified before the Senate, who was denied a CGM after having one under his pre-Medicare private insurance, was lucky to be alive and share his story. He was traveling down the highway when he suffered a severe low. Because he has lost his hypo awareness, he lost control of his car. An alert driver in an 18-wheeler, was able to guide the car safely into the median strip.

It was heartbreaking to hear his story. A revered, successful coach, intelligent, alert, vibrant, he has pursued every avenue of appeal and at every single turn, even after receiving an Administrative Law Judge’s approval, he was still denied. He is not alone, @Richard157 is not alone, but they and so many others will benefit from having a CGM.

4 Likes

You have a way with words, YogaO. Thanks so much for telling us about the coach. I test 15 times each day, including three times during the night, to help compensate for not having a CGM. But I still have some lows. Nothing can fully replace a CGM.

1 Like

Richard157, you say you test 15 times per day. What I’m wondering is if insurance pays for that many testing strips or if you have to supplement out-of-pocket. How many tests per day does your insurance allow?

My doctor, several years ago, approved 6 tests per day. A year later he approved 8 per day. Showing him my charts enabled him to see that more testing improved my control, so he approved 10 times per day. That is the maximum he will approve. I use Walmart’s Relion Confirm meter for an extra 5 tests per day. Relion strips are cheap, and the meter is accurate.

I’ve been to the ER for severe hypoglycemia twice in 32 years, both before I started using a CGM (and my hypo-alert dog!). I don’t remember the exact costs but it was thousands and thousands of dollars.