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DME MACs finalize CGM coverage

DME MACs finalize CGM coverage

WASHINGTON – The DME MACs have released the updated LCD and Policy Article for continuous glucose monitors (CGMs), finalizing expanded coverage.
To be eligible for coverage of a CGM and related supplies, the beneficiary must meet all of the following initial coverage criteria (1)-(5): 

  • The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses); and, 
  • The beneficiary’s treating practitioner has concluded that the beneficiary (or beneficiary’s caregiver) has sufficient training using the CGM prescribed as evidenced by providing a prescription; and, 
  • The CGM is prescribed in accordance with its FDA indications for use; and, 
  • The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the criteria below:  
  • The beneficiary is insulin-treated; or, 
  • The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the following (see the policy specific documentation requirements section of the LCD-related Policy Article (A52464)):  
  • Recurrent (more than one) level 2 hypoglycemic events (glucose <54mg/dL (3.0mmol/L)) that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan; or, 
  • A history of one level 3 hypoglycemic event (glucose <54mg/dL (3.0mmol/L)) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia 
  • Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare-approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria (1)-(4) above are met. 

The effective date for the new LCD and Policy Article is April 16, 2023, a few weeks before the anticipated May 11 COVID-19 PHE end date.  
You can view the DME MAC's response to the comments here.


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