Medicare coverage of cgm *and* test strips

Type 1 and LADA
22

This information given above is for test stripsonly, when you are getting a cgm from a supplier elsewhere.

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23

Ah. Ok. Since Walmart still have my Contour strips prescription that is worth a try. Probably best with a one-on-one when I pick up my Omnipods; they are on Part D and Iā€™ve had no problems but Walmart refused point-blank to contact my insurance for my original G7 prescription. They said Medicare didnā€™t pay for CGMs!

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John,
I have to get my cgm through CCS medical. They kept telling me they donā€™t supply test strips. Medicare would tell me they covered them if they ere bundled with the cgm. This went on for years until my minimed rep told me to have the pharmacy run them has (test strips for adjunctive CGM) The pharmacist said there was no place to put that so I assume he made a phone call and magically they started going through. Good luck, it would be nice to hear you are successful!
Dawn

25

Hi Dawn. In the hopes of making it easier next time you try to get test strips hereā€™s a definition from Medicare Part B Article - Glucose Monitor - Policy Article (A52464).

An adjunctive CGM requires the user verify their glucose levels or trends displayed on a CGM with a BGM prior to making treatment decisions.

The only adjunctive CGM currently(?) sold is the Medtronic Guardian 3. All the current Dexcom, Libre and newer Medtronic CGMs are ā€œnon-adjunctiveā€.

A non-adjunctive CGM can be used to make treatment decisions without the need for a stand-alone BGM to confirm testing results.

Eventually an audit would have found the pharmacistā€™s mistakes but Rite-Aid closed before that happened. To get test strips in the future you can either use your Part D plan or find a CGM supplier that sells both the CGM and the test strips you use A quirk of the Part B CGM benefit is you have to get the CGMs and test strips, lancets, control solution, etc from the same company. As I said above, the company gets paid $267.92 if they ship test strips with CGMs or not. CCS decided not to sell test strips because it would cut into their profits.

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I do get test strips from the pharmacy under part B. I was trying to explain how I managed to finally get them. Also I was told by Medicare that your CGM supplier gets that money whether or not you get strips. I use CCS and they will not include strips even though Medicare says they are paid a stipend for them.
In my opinion which means nothing to the people who decide what is adjunctive or not. No CGM is non adjunctive, even their paperwork tells you to check before treating.
Thank you for your information.

27

Does something say that specifically for CGMs or is that a consequence of a requirement that a supplier of DMEPOS supply all the necessary associated supplies?

What you are saying makes sense but the sense I get is that test strips are not covered for non-adjunctive CGMs. For adjunctive CGMs (i.e. the Guardian 3) Part B will part for the test strips so long as they are billed under the correct code; Iā€™m just paraphrasing A52464 here.

So back to square one: The vendors of non-adjunctive CGMs tell Medicare that test strips are not necessary but then they say in their literature that they are. This is perfectly legal but highly immoral; test strips are not required for blousing (the Medicare distinction) but are certainly required for not suffering an ā€œadverse eventā€ (hypo or hyper).

It can only get worse.

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John, nothing says it specifically which is a good point. Hence me calling it a quirk. We know that Medicare pays a flat fee for 30 days of CGM supplies that includes sensors and test strips. We also know that Medicare forbids billing for items that are already covered by a comprehensive code (unbundling). If Edwards gets paid the flat fee for your 30 day CGM supply allowance which include test strips, no one else should get paid by Part B for test strips. PM me if you want the details from the policy/lcd/ncci/dmemac.

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Agreed:

o When the rules are unraveled the G7 is ā€œnon-adjunctiveā€ (if I got that the right way around) so a user canā€™t bill for a BG test system for bolusing.
o The G7 is billed as a DME whereby all necessary supplies are included in the price.
o The G7 does not require calibration, so no test strips are required for calibration.
o The G7 never gives erroneous results so, despite the clear instructions, there can never be a requirement for test strips to double check the mighty pronouncements it issues, akimbo.

So, sarcastic statement asside, Edwards can reasonably say that test strips are not required with the G7, Medicare is just paying for everything necessary and we are toasted.

30

Hi all,

Thanks to everyone who participated in this thread - all with excellent points.

It took more than a few days (actually about 3 weeks) to finally get to the bottom

of this issue. Final result: Medicare will not pay for test strips if you use a G7. I had

several conversations with ADS and initially got some inconsistent responses that

gave me some hope but after a lot of back and forth I got nowhere other than

from where I started.

So Iā€™ll continue purchasing Contour Next strips online and keep searching for the

best price availableā€¦.

thanks again,

ā€¦bobā€¦

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31

Thanks for letting us know how this turned out for you.

If you want to keep trying to get test strips from ADS because medicare is already paying for the testing supplies that ADS isnā€™t sending you hereā€™s the Medicare Part B DME complaint process: Competitive Acquisition Ombudsman (CAO) | CMS Gotta love government websites, hiding a complaint process under competitive bidding section is typical. Reference Medicare policy A52464 ā€œFor non-adjunctive CGMs, the supply allowance (A4239) also includes a home BGM and related supplies (test strips, lancets, lancing device, calibration solution, and batteries), if necessary.ā€

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32

Edwards did not reply, respond or in any way express themselves after my request that they send me some test strips. If I felt like I could spend a year or so stressing myself out by claiming my rights I would do as you suggest, as I suspect would most of the 65 year olds using AIDS in the US.

They win by grinding us down. In this case it almost certainly only takes one person to do it but thatā€™s the way in most cases; there are just too many cases of this. Uurgh. How do we change this place to be compassionate not money-grabbing.

I remember when I first came here (in the Clinton era, the one with the cigar) that every person I met in the Federal government (maybe not so much the CA government) was friendly, helpful and caring. I came from the UK where that was not so. Other people, car salesmen, landlords, no so much so, indeed the opposite. Maybe we are heading in the wrong direction?

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