Medicare denial of CGM devices

Continuing the discussion from How does Medicare coverage of CGM affect you?:

Richard, I am also on Medicare and intend to use Dexcom CGM. I have been reading up on the subject of Medicare denial of CGM. I have looked for text similar to yours. Here is what I found:
"… will cover 72-hour continuous glucose monitoring for patients with labile blood sugars and the need for intensive short-term monitoring for improving blood glucose control." Is this the wording in your denial? Can you scan the document or take a picture using your cell phone and attach it to your reply.

There has been a major win for a TYPE 1 Patient recently in a Court case WHITCOMB v. BURWELL on May 26,2015 in United States District Court, Wisconsin. From what I have read, the support for Medicare’s denial is specific in an earlier article A47238 which has been superseded by LCD (Local Coverage Determination) 27371, which does not contain any reference of CGM. So the Medicare denial is in error.

From a review, “the Secretary, through the Medicare Appeals Council, erred when it concluded that A47238 is incorporated into LCD L27231. Nothing in LCD L27231 attempts to incorporate A47238”… which unambiguously states that continuous glucose monitors are considered precautionary and not covered by Medicare. [Decision page 8] “If the reference to the continuous glucose monitors contained in the Article had been included in the LCD, the outcome of this case likely would be different. But the fact that the LCD is silent as to whether continuous glucose monitors are covered is not a matter the court can overlook.”

see review https://disqus.com/by/disqus_YOfNRxfbdg/

So, my guess is that Insurance Company has found language in existing Articles to deny coverage.
I know in my case my insurance will deny coverage for my CGM. I am getting ready for the long battle. The Diabetic person in the above case fought his way through 5 levels of decisions. The first two levels were denials, the next overturned the denials and approved, the next overturned the previous level and denied and finally District Court found for the Plaintiff, the patient.

I learned something today. As they say, “follow the money”. Medicare will not cover my CGM sensors either. In the process of buying them directly from Medtronics, I used to have them bill, through Medicare; then Medicare would deny them, my supplemental insurance would follow suit (as they only pay for cost on covered items that exceed Medicare approved amounts) so I’d be paying the full amount. The cost was $473 for a box of 5, each month, or $$5600 per year!!
If I elect to have Medtronics bill me directly, teh cost drops to just under $170 for the 5. When questioned, I was informed that the $473 is the contracted amount for Medicare/ Insurance purchases.
Now, I am sure Medicare knows about this pricing arrangement. So, I suspect that Medicare refuse to be screwed, by this huge discrepancy, so their response is to refuse coverage. Who’d have known???

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Thank you for a concrete example of the phenomenon I’ve been trying to shed light on forever— when a third party pays for something, the price invariably rises. It this case it rose past the breaking point for millions of people.

I have a Medicare Advantage Plan, through Excellus BC/BS here in NY. They covered my CGM without any problem what so ever. Preapproval was needed and the kit and 3 boxes of sensors were approved without any first time denial…And I’m a Type 2 Diabetic…Only problem I have is Nocturnal Hypoglycemic unawareness while sleeping…I’m guessing that as the reason why BC/BS approved it straight away…

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I assume “Excellus” is an insurance arrangement of some type.
Well, further investigation reveals that this pricing structure was apparently arranged with the Fed Govt. to prevent Medicare from participating in any competitive bidding situation, so that the medical device makers would not vigorously, nor publicly, oppose Obama Care. This scenario makes a lot of sense, when you think about it. Why else would any purchaser willingly agree to pay almost twice as much as other buyers, for essentially the same product. As I said, “follow the money”.
I mean, why would my privately paid insurer cover this, with a High Deductible, with almost NO objection? I asked and they figure it is less expensive than emergency room visits and/or other complications.

We have switched to the dexcom G-5 sensor because Medicare will pay for it. We also are using aMedtronic530g because it’s paid for by Medicare. My question is: can someone tell me why Medicare will not allow me to track my husband’s diabetes on my iPhone? Thank u!!

@Karen_DiBraccio
lol - Depends.
Are you asking for the technical reason as stated in the Medicare decision.

Or are you asking for the underlying thinking behind what the stated decision is?

IMHO - Two very different things. The first is factual. Black and White. The second is opinion and open to endless discussion with no real way of knowing the actual truth.

Would b interested in both :slight_smile:

@Karen_DiBraccio
So the actual language:

https://med.noridianmedicare.com/web/jddme/policies/dmd-articles/coding-and-coverage-therapeutic-continuous-glucose-monitors

[particular pieces cut-n-pasted from the link above to the quotes below]

CMS Ruling 1862R recognizes that therapeutic CGMs are durable medical equipment (DME) under section 1861(n) of the Act; therefore, they fall within the scope of Medicare Part B benefits.

For purposes of Medicare billing, the Ruling outlines therapeutic CGM as comprising two elements: (1) a DME component and, (2) an all-inclusive supply allowance. The DME component for the Dexcom G5® Mobile CGM system is the receiver.

The supply allowance for supplies used with the Dexcom G5® Mobile CGM System encompasses all items necessary for the use of the device and includes, but is not limited to: CGM sensor, CGM transmitter, home blood glucose monitor and related BGM supplies (test strips, lancets, lancing device, and calibration solutions) and all batteries.

The Medicare DME Benefit excludes coverage for non-medical items, even when the items may be used to serve a medical purpose. As a result, smart devices (smart phones, tablets, personal computers, etc.) are non-covered by Medicare under this exclusion. Likewise, medical supplies used with non-covered equipment are not eligible for Medicare reimbursement.

Coverage of the CGM system supply allowance is limited to those therapeutic CGM systems where the beneficiary ONLY uses a receiver classified as DME to display glucose data. If a beneficiary uses a non-DME device (smart phone, tablet, etc.) as the display device, either separately or in combination with a receiver classified as DME, the supply allowance is non-covered by Medicare.