Skip to Content

CMS proposes modifications to CGM coverage 

CMS proposes modifications to CGM coverage 

WASHINGTON – CMS has published a proposed LCD that modifies the coverage criteria for continuous glucose monitors (CGMs) based on the best available evidence. 

The agency seeks to modify criteria to allow coverage of a CGM for beneficiaries with diabetes mellitus who are insulin treated or have a history of problematic hypoglycemia. Problematic hypoglycemia is defined as: 

  • recurrent level 2 hypoglycemic events (<54mg/dL (3.0mmol/L) that persist despite multiple (2 or more) attempts to adjust the medication dosage(s); or the diabetes treatment regime; or 
  • history of one level 3 hypoglycemic event (<54mg/dL (3.0mmol/L) requiring the assistance of a third-party for treatment of hypoglycemia. 

Other changes: 

  • Removing the requirement for frequent adjustment of the beneficiary’s insulin treatment regimen on the basis of the home blood glucose monitor (BGM) or CGM testing results. 
  • Retaining the requirement for a visit with the treating practitioner every six months to assess adherence, although it has clarified language to specifically address the long-standing policy that allows for the use of Medicare-approved telehealth visits.  
  • Eliminating the intensive insulin management requirement and the inclusion of telehealth options may also promote health equity for vulnerable rural and non-Asian ethnic minorities, as well as Medicare beneficiaries in areas with health care-professional shortages. 
  • Not extending coverage to beneficiaries solely on the basis of having stage 3-5 chronic kidney disease, gestational diabetes mellitus, bariatric surgery or pancreatectomy who do not otherwise meet the outlined coverage criteria. 
  • Adding criteria to ensure the CGM is being used in accordance with FDA indications and the beneficiary has received proper training in the use of the device. 
  • Continuing to allow CGM supply allowance to be billed monthly, as it is not within the purview of the DME MACs to modify this requirement.  

Comments

To comment on this post, please log in to your account or set up an account now.