Medicare and CGM's

I am pushing 70, on Medicare and have also been denied CGM coverage. I can have a BG of 35 and no symptoms at all. I think it is a normal accomodation to keeping BG low, which is the only way to survive without complications. I understand that, if you persist and have physician support, you can eventually succeed. Dr Steve Edelman, an endocrinologist from UCSD, says that we apparently are no longer type 1 diabetic once we turn 65.

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Hello Calferness, I looked for Dr Edelman’s statement. I think he was referring to the actual diagnosis made after an individual is 65. Then it is LADA, and not the typical type 1.

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It was actually a sarcasm relating to the lack of CGM coverage for t1s by Medicare. He made it with reference to his soon turning 65 (he’s been t1d since childhood). This particular comment might not be something you could find in a search.
Clif

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Ah, right. I didn’t catch that it was snark either. Pretty decent snark too.

I just found out that as of about a week ago Medicare will cover CGM’s. They are still figuring out the paperwork but they are now covered.
Dexcom told me that because of a classification change Medicare is now supporting them.
Go to Dexcom.com fill out form with your information and they will get back to with info.
Been a long road getting here and I don’t know who to thank. That’s all the info I have right now.

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good info here about this development

I have read that the only CGM that will be covered by Medicare is the Dexcom G5. Have you read something different? I am using the Dexcom G4, and I love it so much! I am thinking that the G4 will not be covered. I have also heard that the people asking to be covered will be handed on a case by case basis. There is a list of criteria that must be met to get coverage. One of them requires that we do not feel our lows and we depend on our CGM for that reason. If I get my endo to write a letter of medical necessity, I don’t think she would say that I do not feel my lows. Occasionally I don’t, but usually I do feel them. On that point alone I probably would not be approved.

@MarieB I have been told that there will be more information from Medicare soon and probably more suppliers will be contracted. I have been told April 15 by more than one source. I don’t know whether more strict criteria will be implemented, but I have been told that there were be more regulations.

Some people are already getting supplies from Liberty, but most are having to say that they will pay the cost if Medicare does not approve them or their secondary does not pay. At the same time, some of those people say that they did not have to give credit card info to Liberty and were still shipped supplies.

I started Medicare on Saturday and am starting with getting organized for pump supplies before tackling CGM. I have to get a C-Peptide test along with a fasting BG before I am eligible for pump supplies. This will be my first C-Peptide test ever because I was diagnosed long before the test existed. Fortunately I have enough sensors to carry me through for a couple of months. I use each sensor for 3 weeks, so 2 months is only 3 sensors.

@Richard157 The G4 will not be covered by Medicare because it has not been approved by the FDA for dosing insulin. I doubt that Dexcom will try to have that changed because they want to move away from G4 except for those who require it for certain pumps. They do not make as much money off of the G4 because the transmitters last a long time. The G5 is a better financial model because you are required to purchase a new transmitter every 100 days. The G6 is expected within a year and will have more accuracy, fewer calibrations, and a new inserter. That is Dexcom’s future, not the G4. I would be very disappointed if my endo would not be willing to write a letter of medical necessity for me and IMO it only takes 1 low that you don’t feel to cause an emergency.

On another subject–If I had to guess, I would think that Medtronic will not try to get the Enlites approved by the FDA for insulin dosing and will instead put all of their eggs in the basket of the new sensor system to be released with the 670G. Since the 670G will be dispensing insulin continuous based on sensor readings, it seems hard to think it isn’t approved by the FDA for dosing insulin. The Enlites have a higher MARD than the Dexcom G5 and it is very possible that they wouldn’t be approved for therapeutic use by the FDA anyway. That’s of course my own opinion. :grinning:

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Thanks Laddie, that is good information.

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Again the paperwork/wording hasn’t been finished yet. Latest date ia April 15 but that is the 3rd 15th Liberty has been told. :confused: Goverment ?

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Richard, I don’t mean to be flippant, but you can point out to your doctors that you don’t feel low when you are sleeping. This, to me, is good enough reason for the MD to write you a letter of medical necessity.

In my 33 years with T1D, I’ve gone from feeling almost every low to not feeling any low to now feeling most lows. Do you really feel every low? “Usually feeling a low” is not good enough when you treat with insulin.

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@Terry4, when my BG drops fast I always feel the lows. My body does not have time to adjust under those circumstances, and I can feel the lows when I am in the high 70s. When I drop slowly my body does adjust enough that I am much less likely to feel lows, and I may not notice until I am in the 50s. That is when I need a CGM that will enable me to see the trend long before I reach the 50s. That can happen both day and night. I think my endo will write a letter for me. I am expecting Medicare to be very stubborn, and not accept every request for coverage. I am thinking it will be handled on a case by case basis.

Richard – The last I’ve read is that the process has moved beyond the “case by case” basis stage. This March 24, 2017 Dexcom press release shows four criteria that must be met for Medicare coverage. The process is new yet coverage seems imminent.

If I were you, I’d closely follow Laddie’s coverage of this topic as she’s new to Medicare as of just a few days ago and has this process under scrutiny. She intends to get Medicare coverage for a Dexcom G5 CGM.

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Hi All,
It is interesting to note that there are some hidden factors in the original CMS Ruling CMS-1682-R. It would be wise to read the document in total. What the ruling has accomplished is to wipe out all of the prior successful appeal winners.
Meaning no coverage at all under the new bill. Next, read the historical section in the beginning. The FDA was real clear sensors have a warranty period of six or seven days for safety reasons. When one changes a sensor each and every seven days, 365/7 = 52 sensors. The Medicare plan is to only cover one box per month. For a Dexcom user that would mean a total of 48 sensors. Four sensors to a box would mean that we would be missing coverage for 28 days. There has been a May 4 release. You cannot use the connection factor to share your results with another friend or family member. If you do you will lose coverage for supplies. The last major point is an attempt to force linkage of the number of blood glucose strips. Medicare is requiring a substantial drop, cut, reduction in the number of blood glucose strips. Liberty Medical out of FA was the supplier for primary Medicare. Liberty Medical has left the marketplace effective May 28th. There are no
medical suppliers for the Dexcom 5. What happened to me was a complete blackout of the prior approvals for Dexcom G 4 products. I have had two back up back denials for an upgrade to a Dexcom 5. Your physician is being required to use an entire set of new codes. Wrong codes and language you will be denied. This a major mess with no clear direction except for total control by Medicare. Be careful. Be sure you and your physician are up to speed with the ever-changing rules and reg.

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I had heard about the drastic cut in number of strips allowed. That is how they plan to save money. But with regard to “you cannot use the connection factor” — how in the world would they ever know?

I do not know. However, that responsibility could fall on the supplier of the transmitters and sensors and blood glucose strip allin a single order.is one possibility.
Dan

Can you elaborate on your statement about Medicare decreasing the amount of test strips. I have a hard time keeping up with all the new changes. I have sent my first appeal for CGMS ( Medtronic) and have received the denial. Sometimes I feel like I would rather use all this effort( fighting for coverage) to keep healthy. The stress is really becoming a factor. I don’t look at it as giving up the appeal process but just changing my focus to my own personal needs and working out positive ways I can develop to get along with less strips and sensor coverage.

Hi KAK,

Here is the link. https://www.cgsmedicare.com/jb/pubs/news/2017/03/cope2581.html

Check out the paragraph which begins . . . ." The supply allowance for supplied used with the Dexcom G5 encompasses items . Look at the list on the items which are proposed to be linked to the DME category for the Dexcom G 5.

Ok for those that have been waiting on a CGM to be covered by Medicare as most know Dexcom G5 will be the only one right now. But nobody was quite sure who would be the supplier. Liberity dropped out as did the rest.
After just speaking with Dexcom they will be doing the supplying them selves. Rep that I spoke with said the decision was just made. Said about 4hrs ago, not sure about that, but :smirk:
Anyway those interested go to Dexcom web site fill out questionnaire took them about 15min to get back to me, no joke.

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Hi KAK,
There is a more recent notification which is dated May 4, 2017 regarding this matter.
Read item 5.
Continuous Glucose Monitors – Frequently Asked Questions

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Continuous Glucose Monitors – Frequently Asked Questions
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It is far more comprehensive. It includes, blood glucose strips, blood glucosemeter(s) and batteries. Really???
Dan