Will the Dexcom G7 lose Medicare Part B coverage?

Continuing the discussion from G6 transmitter:

@MM1’s comment in the G6 transmitter thread made me realize that the Dexcom G7 will not likely be covered under Medicare Part B due to its loss of a durable component.

Yikes! I currently receive my Dexcom G6 supplies (sensors + transmitters) as covered by Medicare Part B (traditional, not Advantage Medicare). Since I also have a supplemental policy, I enjoy zero dollar out-of-pocket expense. It looks like that fortunate reality is about to change.

If your logic about the loss of DME coverage (makes sense to me) holds, it looks like I might lose all coverage of Dexcom CGMs beginning with the G7 version. The Dexcom G6 line should survive for some time after the G7 is introduced but the G7 design with an integrated throw-away transmitter seems to be the way of the future.

The Medicare Part D Rx coverage I hold does not cover CGMs. It’s possible I could shop for and find Dexcom Rx Medicare coverage but I doubt it.

I guess that means that I need to bolster my G6 supply by restarting sensors.

Anyone else surprised by this?

I highly doubt Dexcom would let Medicare coverage go, as that’s a big part of their business. They’re going to jump through hoops to make it happen. Medicare writes their own rules, so they can write anything they want into the rules. Dexcom just has to make it worthwhile to them.

Working with insurance providers for coverage and which channels it goes through is all part of the rolling out new tech process. The goal of every tech company is to grow, through. They won’t be making any moves that will deliberately cost them patient base.

I would question the definition of “durable”. It may be just the fact that it’s intended to be used for 14 days (eventually) qualifies it as durable, as opposed to a pill that disappears after 1 use or a test strip that is useless after 1 result. With 10 days wear, a sensor is capable of giving 2,880ish readings, being reused each time. I think they could be construed as durable if the paper pushers want it to be, even if you do throw it away eventually. .

Or maybe certain CGMs will finally be covered under pharmacy benefits?

Remember with the G6, Medicare rollout was slow, too. We may see something similar where 6-12 months go by before Medicare users are switched over. I would personally be relieved by that, as it means that the G6 will remain available. I’m terrified about not being able to restart the G7 and not affording it! Though I’m sorry my relief comes at the deprivation of others.

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I hope that your analysis holds true but I am not persuaded at this time. I’ve watched Medicare’s persistent refusal to designate the Omnipod pump as durable. This important decision has denied people on traditional Medicare who use an Omnipod pump to get their insulin supply covered as part of their system that includes a durable component. For Medicare people, the Omnipod is only covered under a Part D pharmacy benefit.

Yeah, I remember that, too. Medicare beneficiaries had to wait at least a year for coverage after the product was introduced. Dexcom was struggling to meet demand for this new product and holding off the Medicare crowd gave them time to ramp up capacity. This did not affect me directly as I was hanging back with the G4 version, content with its rock-solid performance and ability to easily restart.

That’s just the way things happen in our crazy access to medical benefits in this country. Your relief does not cause deprivation of others. And any single person’s use of the system does not impair access for others.

Thank-you for your thoughtful comment, @Robyn_H.

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Okay, here’s another thought and I’m surprised that Robyn didn’t point this out. If a pump company produces an automated insulin dosing system that includes a CGM, then the burden to include a durable component is easily satisfied since the pump is considered durable. I’m picturing the eventual Tandem T:Slim X2 system that includes the G7 CGM. In that situation, I think Medicare Part B coverage will apply to the CGM even though the CGM itself has no durable component.

In that circumstance, only the DIY systems like Loop will preclude Part B coverage for the CGM. I’m not ready to jump to a commercial closed loop system since I find their safety “guardrails” uninspiring. It may very well work for the population, but they don’t for me.

Time will likely cure this predicament as Tidepool has filed with the FDA for approval of their Loop software. I’m hoping that Tidepool is somehow able to remove some of those guardrails to make the system more palatable to people like me. In that case, a system built with Tidepool’s Loop, a compatible pump, and a Dexcom G7 would satisfy Medicare’s need for an obviously durable component.

@Laddie – what are your thoughts?

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I also posted this topic to the Facebook Seniors with Sensors group forum. @Laddie quickly pointed out that it is the Dexcom receiver that provides the eligibility for durability, not the transmitter.

Sorry that I’ve raised this unnecessary concern!

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Another thinking is maybe it is still dme, since a reader device is needed, rather than the transmitter being the durable part.

But I don’t think bg strips were considered supplies for a bg meter.

Anyone know how medicare covers Libre?

Through the years I read many complaints about how Insulet totally botched trying to get the Omnipod covered by Medicare. So when the pharmacy route became available, they jumped at it although it is a great disservice to most people on Medicare. IMO if Dexcom is considered to be DME because of the receiver, then Omnipod should be considered DME because of the PDM.

I hated the Omnipod so this is not my battle. But I am sorry for Omnipod lovers who move to Medicare and pay a huge financial penalty to keep using it.

Kevin Sayer, CEO of Dexcom, has promised that they will not repeat the disastrous G6 rollout and there will be adequate G7 inventory when it is released. But I have heard nothing about Medicare negotiations.

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From dexcom website, the receiver must be purchased and used some of the time, to be covered as DME.

So assuming G7 will have a Dexcom G7 receiver, that must be purchased (for medicare coverage) and occasionally used to meet Medicare requirements.

For G6:

Hope its figured out by the time I get to MC in a couple years.

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G7 will continue to have the ‘argument’ of durable because its integration with pumps.

The other component is the receiver would be needed as a smartphone is not a medical device. So there is still a durable device…

Thoughts now.

From my own experience, DME doesn’t require what we might logically think of as a “durable” components. I have an ileostomy and all of my supplies are covered under Part B, even though not one piece of the system is used for more than a few days before disposal. There’s nothing mechanical, electric nor electronic. Adhesives, flanges, pouches/bags.

I don’t have a comprehensive understanding about how the Medicare system works. My only knowledge of the Medicare Part B durable medical equipment coverage is from my experience with my continuous glucose monitor (CGM) coverage.

When Dexcom enabled the G6 system to provide display via a dedicated receiver and an optional smart phone, Medicare made a big deal out of the point that coverage hinged on patient use of the receiver. They made it plain that we had to at least occasionally use the receiver or Medicare could deny ongoing coverage without that occurring.

Now you are saying that your ileostomy supplies without any durable component qualifies for Medicare Part B via the DME provision.

The DME coverage is under the larger Part B coverage. I believe that my doctor appointments, for example, are covered under Part B. Is it possible that your ileostomy supplies are covered under the larger Part B, like a doctor’s visit, and do not need a durable component to provide eligibility?

I don’t know the answer to this question. Perhaps someone else can provide clarification. I do know, however, that to qualify for Medicare Part B DME, a durable part of the system is required. The Omnipod insulin pump was excluded from Part B DME coverage for this very issue.

I’m visualizing this as a Venn diagram with a large circle labeled as Medicare Part B and within that circle is a smaller circle that is labelled as DME.

Edited to add: I did a quick search and found that all ostomy supplies are covered under Part B because they are considered a prosthetic device “needed to replace a body part or function when a doctor or other health care provider enrolled in Medicare orders them.” So using my Venn diagram described above you may add another small circle to the larger Medicare Part B circle. That small circle is labelled Prosthetics.

Medicare info on ostomy supplies.

https://www.medicare.gov/coverage/ostomy-supplies

Part B covers many things, and different rules apply.

In case of ostomy supplies (per above), it requires that the surgery was performed first. This is equivalent of a “DME” dexcom receiver (or tandem pump) as the “thing” that drives need of consumable supplies. Assume it doesn’t matter if the “thing” was originally acquired while on medicare.

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Remember, they get to re-write their own rules anyway they’d like. This has just about nothing to do with the definition of DME and what qualifies, and more to do with not wanting to buy people new iPhones because it’s part of their CGM system. By requiring use the receiver, they circumvent this “need” for a non-medical component to a medical system.

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And we need to be aware that the new, expensive bills in the House right now may significantly redefine Medicare coverage by removing coverage for certain groups while increasing it for “underserved” populations (meaning more common conditions not currently covered, not certain groups of people). Just something to watch, as I’m sure that Congress doesn’t know most of the ramifications of things they vote for.

@Terry4 and others.

This thread is a hypertensive crisis with out a foundation. Until Medicare in its theocracy declares above all else the rule, all discussion is bathroom chatter or even worse, rumors behind the barn.

Hope this helps.

Your comment seems dismissive to me. I started this thread since I worried that the Dexcom G7 system, absent the durable transmitter of previous generations, might be considered ineligible for Medicare Part B coverage.

Other members reminded me that Medicare’s past communication with beneficiaries identified the discrete receiver provided that durable eligibility. So, my initial question was built on ignorance, something I once knew but temporarily forgot.

I, for one, appreciate this type of peer support. As I age, I’m fearful of losing a cognitive step or two and I take comfort knowing that my tribe will help remind me of what I once knew but forgot.

I also know that many US members here are not aware of how Medicare works and they can become familiar with the issues as they move closer in time to Medicare eligibility.

I consider the ancillary speculation that occurs in threads like this as simply the “overhead” of dealing with any community. Please refrain from dismissing the the entire thread due to the marginal speculation that may arise.

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@Terry4 , you are 100% correct. My thought was let’s not raise the alarm until we are certain there is something meriting an alarm.

Medicare is a conundrum in and of itself, clever to prevent beneficiaries from having concrete, specific communication, like web transcripts, etc that may be used to say “see, you said” on any issue.

As a Medicare beneficiary & 20+ year Dexcom user, it is my firm belief this entire incendiary thread is a gravely premature chicken little, the sky is falling alarm, whose sole purpose is to incite develop a “woe is me”, I’ve been screwed, tsunami.

Please, reconsider the intent of my comment. This intent is best directed toward members of the US Congress. Of course a large group of monkeys is call a congress also. Just my perception from inside the political arena.

Thanks, I hope you understand my position.

Sorry Jay, I do not accept that this is an incendiary thread intended to promote “chicken little” behavior.

@Terry4 , check out the two characters from the Muppets by Jim Henson named Statler and Waldorf. You choose one, I am the other…

Two sides of the same coin…

Not sure I agree with the analogy, in fact I don’t identify with being a grumpy old man. I do see in myself, however, strongly held beliefs built on years of experience, especially those informed by success in treating diabetes, but more recently appreciate the fact there’s often more to consider that I don’t see. My humility is a work in progress but I appreciate the wisdom in it.