Does Medicare Cover Continuous Glucose Monitors?

Yes, Medicare does cover continuous glucose monitors (CGMs) for eligible beneficiaries. These devices have become increasingly important for managing diabetes, and updates from April 2023 have made them more accessible to a wider population.

CGMs continuously measure glucose levels through a small sensor inserted under the skin, providing real-time data, alerts for highs and lows, and glucose trend analysis. The benefits for older adults are significant: better glycemic control, fewer hypoglycemic events, and reduced reliance on fingerstick testing.

Understanding Medicare Coverage for CGMs

Medicare considers CGMs durable medical equipment under Part B, provided they meet specific criteria. That means coverage follows the same rules that apply to items like wheelchairs or oxygen equipment.

• Medicare covers 80% of approved CGM costs after the Part B deductible.
• You must use a CGM with a standalone reader, not a smartphone-only system.
• The CGM must be FDA-approved for therapeutic (non-adjunctive) use.
• Patients typically pay the remaining 20% unless they have a Medigap plan.

This classification impacts both coverage and the steps needed to receive a CGM through a Medicare-approved supplier.

Medicare Requirements for CGM Coverage Approval

As of 2023, Medicare eligibility rules are broader, but documentation is still essential. To qualify, you must:

• Have any type of diabetes mellitus (type 1, type 2, or gestational).
• Either use insulin or have a documented history of problematic hypoglycemia.
• Undergo an in-person or telehealth visit within 6 months before starting a CGM.
• Have your provider document medical necessity and training in the medical record.

These requirements reflect changes made through CMS coverage determinations, and they ensure that CGMs are used by patients who are most likely to benefit safely and effectively.

Different CGM Brands Covered by Medicare

Several CGMs meet Medicare's standards and are widely used. The most common options are:

• Dexcom G6 and G7: Real-time sensors with alerts, covered when used with a receiver.
• FreeStyle Libre 2 and 3: Libre 2 uses scanning with optional alarms; Libre 3 provides real-time readings without scanning.
• Eversense E3 and Medtronic Guardian: Less common but covered in some cases, especially for insulin pump users.
• All covered systems must meet therapeutic use criteria and include a standalone receiver.

Choosing a CGM involves more than brand preference—it depends on how the system fits into your overall diabetes management plan, including ease of use, sensor wear time, and integration with other tools like insulin pumps.

Obtaining a CGM Through Medicare

The process to obtain a CGM can feel bureaucratic, but following these steps can help:

• Meet with your doctor in person or via approved telehealth to review your diabetes history.
• Ensure that documentation includes diabetes diagnosis, insulin use or hypoglycemia, and training.
• Obtain a prescription for an FDA-approved device that meets Medicare DME requirements.
• Work with a Medicare-approved supplier to submit documentation and coordinate delivery.

By anticipating documentation requirements and coordinating closely with your provider and supplier, you can reduce delays and improve your chances of getting the device approved quickly.

Recent Changes to Medicare CGM Coverage

Medicare’s coverage expansion in April 2023 was a game-changer. For years, CGMs were limited to people on multiple daily insulin injections, but that changed with new CMS guidelines.

• Any insulin use now qualifies a patient—not just multiple daily doses.
• People with problematic hypoglycemia are eligible, even if they don’t use insulin.
• An estimated 1.5 million more Medicare beneficiaries became eligible after the change.
• These changes apply to both Original Medicare and most Medicare Advantage plans.

The expansion represents a major step forward in making diabetes technology more equitable and reflective of real-world treatment needs.

Benefits and Use of CGMs in Diabetes Management

CGMs are powerful tools for managing diabetes beyond just replacing fingersticks. They provide actionable insights that improve overall control.

• Real-time readings and alerts help prevent both high and low glucose events.
• Metrics like time in range and glucose management indicator (GMI) help guide treatment.
• CGMs improve A1C levels and reduce glucose variability.
• Some systems integrate with insulin pumps and automated insulin delivery systems.

With consistent use, CGMs allow patients and providers to identify patterns, fine-tune medication plans, and make lifestyle adjustments that contribute to better outcomes.

Challenges and Considerations with CGM Coverage

Despite Medicare's expanded coverage, challenges remain when it comes to navigating the system.

• CGMs must include a separate receiver to qualify as DME, which some patients overlook.
• Documentation must comply with LCDs and follow guidelines like HCPCS code E2103.
• Coverage varies by region and contractor, depending on Local Coverage Determinations (LCDs).
• Delays or denials often happen due to incomplete chart notes or incorrect codes.

For many patients, the issue isn’t eligibility—it’s knowing how to comply with Medicare’s detailed requirements. That’s where additional support can make all the difference.

How a Solace Patient Advocate Can Help

Solace advocates specialize in helping patients through these exact hurdles, offering support beyond what most providers can do alone.

• They help you understand Medicare eligibility and verify whether your device meets FDA and CMS criteria.
• Advocates work with your doctor to ensure proper documentation and timely submission.
• If coverage is denied, they assist with appeals, including submitting justification letters and tracking updates.
• They also guide you through finding a supplier, resolving refill issues, and transitioning between devices or plans.

By partnering with an advocate, you’re not only more likely to get approved—you’ll also have someone in your corner helping you stay on track with your diabetes care over time.

FAQ: Medicare and Continuous Glucose Monitors

1. What’s the difference between a personal CGM and a professional CGM—and does Medicare cover both?

A personal CGM is worn by the patient long-term and used in everyday diabetes management. Medicare does cover personal CGMs if eligibility criteria are met, including FDA approval and use with a standalone reader. In contrast, a professional CGM is used temporarily in a clinical setting—often “blinded,” so the patient can’t see results in real time. Medicare generally does not cover professional CGMs for home use, as they fall outside the durable medical equipment (DME) category.

2. Can over-the-counter CGMs or app-only CGM systems be covered by Medicare?

No, over-the-counter CGMs and systems that rely solely on smartphone apps (without a standalone receiver) do not qualify under Medicare’s DME benefit category requirements. Devices must meet FDA’s therapeutic (non-adjunctive) use indications and include a compatible reader. This distinction helps ensure consistency in coverage decisions and compliance with coding guidelines like HCPCS code E2103 and Local Coverage Determination (LCD) L33822.

3. Do CGMs work with insulin pumps—and how does that affect coverage?

Yes, many CGMs are designed to integrate with compatible insulin pumps and even automated insulin delivery systems. Medicare may cover both devices if each one independently meets coverage criteria. That includes having a qualifying diagnosis, appropriate documentation, and use that aligns with FDA indications for use. Coordination between your CGM and pump can improve time in range and help manage complex insulin regimens more effectively.

4. What supporting documents are needed for Medicare CGM approval?

Your provider must submit chart notes that clearly outline your diabetes diagnosis, current treatment plan, history of problematic hypoglycemia (if applicable), and confirmation that you’ve received CGM training. Additional requirements may include a certificate of medical necessity, signed prescription, and references to specific criteria outlined in the Standard Documentation Requirements Article A55426. Medicare Administrative Contractors (MACs) review these documents during claim processing.

5. What happens if I’m denied coverage for a CGM through Medicare?

If your CGM claim is denied, you can file a Medicare appeal. The appeals process includes submitting a redetermination request, and if necessary, advancing to reconsideration and an ALJ hearing. Supporting your case with proper documentation—especially from a prescribing provider familiar with the Local Coverage Determination rules—is key. A Solace advocate can guide you through this process and help ensure that all technical requirements, such as CG modifiers or supply allowances, are correctly handled.

This article is for informational purposes only and should not be substituted for professional advice. Information is subject to change. Consult your healthcare provider or a qualified professional for guidance on medical issues, financial concerns, or healthcare benefits.

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