Medicare Proposes Expanding CGM Coverage

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Medicare CGM coverage

For years now, continuous glucose monitoring (CGM) systems have become a growing mainstay of diabetes management. These devices, which take glucose readings at regular intervals using a sensor that’s worn for several days in a row, were originally popular for people with type 1 diabetes — providing a safeguard against hypoglycemia (low blood glucose) and major glucose swings.

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But CGM systems are becoming increasingly popular for people with type 2 diabetes, as well. So far, most CGM users with type 2 have been people who take insulin. That’s largely because many insurance providers, including Medicare, only cover CGM systems when they’re used to make diabetes treatment decisions, such as changing insulin doses or dietary choices. But a recent announcement by Medicare could change that.

Rule would remove Medicare CGM coverage restrictions

Last week, the U.S. Centers for Medicare and Medicaid Services (CMS), the federal agency that oversees Medicare, announced a proposed rule that would expand access to CGM systems under the program, as noted in an article at MedPage Today.

Right now, Medicare only covers “therapeutic” CGM systems, or those that don’t require confirming a reading using a traditional finger-stick test before making treatment decisions. Only some CGM systems meet this requirement, and they tend to be more expensive than “adjunctive” CGM systems that require a finger-stick confirmation.

Medicare’s current page on CGM insurance coverage states that “If you use insulin and require frequent adjustments to your insulin regimen/dosage, a CGM may be covered if your doctor determines that you meet all of the requirements for Medicare coverage.” Those requirements include not only which CGM system is being used, but the reasons why your doctor says it’s needed.

But the proposed new rule would classify all CGM systems — not just “therapeutic” ones — as durable medical equipment covered by Medicare, with payment amounts established for the devices and their associated accessories and supplies.

In explaining its proposal to change the rules, the agency writes that “CGMs that are not approved for use in making diabetes treatment decisions can be used to alert beneficiaries about potentially dangerous glucose levels while they sleep,” a worthy benefit even if the person has to confirm their reading with a finger-stick test before taking corrective action.

The explanation notes that “this proposal will improve access to these medical technologies and empower patients to make the best healthcare decisions for themselves.”

Proposal lauded by diabetes groups

The Medicare proposal was immediately praised by the American Diabetes Association (ADA), which noted in a statement that “many of the rules limiting access for patients to CGMs are without clinical merit and limit access for patients who need them, especially lower-income Americans.”

The ADA statement notes that the group is “eager to continue to work with CMS to bring down barriers to technology access, particularly for people with diabetes who have no other way to get this important diabetes management device if their insurance will not cover it.”

The proposed rule change was also praised by the Endocrine Society, in a statement noting that “the current rules governing CGMs often result in significant burdens on both patients and physicians. We are therefore looking forward to working with CMS on this important initiative.”

Typically, proposed rule changes like this one end up being adopted, but they still need to go through a review process before they become official. This process involves soliciting comments from the public on the proposed rule, which will be considered in the agency’s final decision. When the public comment period begins, diabetes advocacy groups will most likely encourage people to participate in this process.

If you think you might benefit from using a CGM system but don’t currently use one, talk to your doctor about the potential burdens and benefits, along with how to navigate insurance coverage — including whether it might be best to wait until the proposed Medicare rule change becomes official.

Want to learn more about CGM? Read “CGM for Diabetes Management” and “How to Pick an Insulin Pump or CGM” and watch “Continuous Glucose Monitoring.” 

Quinn Phillips

Quinn Phillips

Quinn Phillips on social media

A freelance health writer and editor based in Wisconsin, Phillips has a degree from Harvard University. He is a former Editorial Assistant for Diabetes Self-Management and has years of experience covering diabetes and related health conditions. Phillips writes on a variety of topics, but is especially interested in the intersection of health and public policy.

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