Medicare exceptions for CGM

(apologies if my search of the forum missed an existing thread)

I’m a T2. Until recently I’ve managed to keep my A1C just under 7. Since diagnosis almost 20 years ago I’ve wanted to know what happens to my BGL during the day and how it responds to certain foods. Since I don’t meet the Medicare requirement of using insulin 3x a day, I decided to purchase the Freestyle Libre 2 out of my own pocket.

I quickly learned what I wanted to know and it has managed me to get my A1C down to 5.1 as of yesterday in a 3 month period since my last A1C test.

I don’t want to get to where I have to use insulin 3x a day. I think managing to get to 5.1 without lows is good and I wouldn’t have been able to do it without the monitor.

So (finally) here’s my question - is anyone aware of Medicare making exceptions if supported by my dr? And has anyone had their dr fudge the insulin usage to get qualified (and I know this is unethical if not illegal but I had to ask).

Thanks.

Just as a point of information. Medicare fraud is a VERY serious offense and carries severe penalties. Having to pay back many times the amount you and the doctor defrauded the government as well as the doc no longer being able to participate in the Medicare program going forward.
Experts believe that under 7.0 is fine. If you want better, you may need to continue to pony up

Thanks. I kind of knew that. I was more interested in whether anyone had tried to get an exception. And I suspect the answer to that will be there are no exceptions.

I have tried2 times,been denied. Visually impaired and have hand tremors take basal and once a week injectable. That is my story.Nancy50

I don’t know of non-insulin users getting CGM coverage with Medicare. The requirements are very clear. I think the requirements will change within the next couple of years as more people with Type 2 are using different medications than insulin. And I know that both Dexcom and Libre are drooling at the money to be made in the Type 2 market. But I wouldn’t expect a change in Medicare policy anytime soon. Looks like you are doing great and have learned a lot with your CGM.

Thanks Nancy50, I also have hand tremors (ET) but fortunately not bad enough yet to cause problems.

Thanks Laddie. I have a long term T1 friend and she is always telling me I over think my T2. Rightly or wrongly I feel like the closer I can get to a “normal” BGL they better I will be but I’m not really complaining. If I wasn’t retired, I wouldn’t think twice about the extra cost but I’m pinching pennies these days.

I consulted with an RD who suggested I use a sensor periodically instead of regularly and that’s what i’ll probably do.

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The Libre is a great choice for periodic use because unlike Dexcom G6, you don’t have a transmitter that expires whether or not you are using it. The Dexcom G7 will have a built-in transmitter but it hasn’t cleared the FDA yet. Plus Dexcom is substantially more expensive than Libre.

My guess is that you will do fine with periodic use. At the same time, the information is addictive and helpful and I suspect is that you will feel “naked” without your Libre.

The author of this blogpost is Type 1 so his story is somewhat different than yours. But you might be interested in his analysis of Dexcom versus Libre.

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Yes, there are no exceptions, exemptions or any kind of bending of the rules, however, nothing stops you from taking a very low dose of insulin 3 times a day, perhaps 1/2 unit or less each time. Even if you buy your insulin out of pocket, your insulin cost could be well under $20 a month which would be a bargain and minimal inconvenience to have your Dexcom supplies fully or mostly covered by medicare depending on your plan.

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