Continuous Glucose Monitoring (CGM)

Medicare Coverage and Ordering for Personal CGM

Medicare has eligibility requirements that must be met in order to provide coverage for personal CGM. This resource will help you navigate Medicare’s eligibility requirements for initial and continuing coverage, ordering and insurance authorization, and documentation. Note that this applies to traditional Medicare, and individual Medicare managed plans or Advantage plans may vary.

Medicare Eligibility Requirements for Personal CGM

• Diagnosis of diabetes; 
• Beneficiary (or beneficiary’s caregiver) has sufficient training using the CGM prescribed;
• The CGM is prescribed in accordance with its FDA indications for use;
• The beneficiary meets are least one of the criteria below:
  • Is insulin-treated; or,
  •  Has a history of problematic hypoglycemia with documentation of at least one of the following:
    • Two or more level 2 hypoglycemic events (glucose <54 mg/dL) that persist despite multiple modifications to the treatment or medication plan,
    • One level 3 hypoglycemic event (glucose <54 mg/dL) characterized by altered mental and/or physical state requiring third-party assistance for treatment.
  • Seen for diabetes management in past 6 months.
  • For continuing eligibility, all of the above must continue to be met.

Medicare Ordering and Continuing Coverage

Once you and your patient have determined the patient meets Medicare’s requirements to cover personal CGM, follow these guidelines for ordering and authorization. Medicare coverage requires CGM to be used in conjunction with a reader. Even if a patient uses a smartphone, smartdevices are not enough by themselves to be covered by Medicare.

Gather Information for Ordering and Insurance Authorization

• A Prescription is Required: Many EHRs support directly prescribing CGM as you would any medication. 
• Choose a Supplier: Medicare covers CGM through the durable medical equipment (DME) benefit, not through the pharmacy benefit.
• Certificate of Medical Necessity: Save it locally so you don’t have to complete repeating information each time.
• Chart Notes: Some order forms also ask about frequency of glucose checks.

How to Order CGM by Brand

Medicaid Coverage and Ordering for Personal CGM

Eligibility

Medicaid coverage for for Personal CGM varies from state to state. Become familiar with your state’s coverage policies. Revisit these policies periodically, as Medicaid coverage for for Personal CGM can change quite frequently. If your state has limited coverage currently, continue to monitor coverage requirements, in general, coverage for CGM has tended to expand.

State Medicaid programs range from offering broad coverage for for Personal CGM to  none at all through fee-for-service.

Questions

When exploring coverage, answer these questions:

• Does my state Medicaid program cover for Personal CGM
  • …for my patient’s diabetes type?
  • …for my patient’s age?
  • …through durable medical equipment or through pharmacy (or either)?
  • …if prescribed by my specialty?
• What information is needed as part of Prior Authorization?
• What other coverage criteria exist? (e.g., is there a minimum number of finger stick glucose checks required? Minimum number of insulin doses per day?)

The resource, Expanding Medicaid Access to Continuous Glucose Monitors, contains a map and detailed table in Appendix A outlining each state’s coverage for type of diabetes, population (pediatrics/adults/both), benefit from pharmacy or DME, requirements for minimum of 4 daily finger stick glucose checks, and prescriber specialty.

Gather Information for Ordering and Insurance Authorization

Gather the documentation required. This usually includes:

• A Prescription: Many EHRs support directly prescribing them as you would any medication.
• Certificate of Medical Necessity: Save it locally so you don’t have complete repeating information each time.
• Chart Notes

Eligibility and ordering guidelines for personal CGM vary state by state. An example using the state of Colorado is outlined below. Most states will follow similar steps for ordering.

Colorado Medicaid Eligibility Requirements for personal CGM: To be eligible for Colorado Medicaid coverage of personal CGM, the following requirements must be met:

• The patient self-monitors glucose at least 3 times daily (e.g. fingerstick blood sugars);
• The patient is treated with 3 or more daily administrations of insulin or administers insulin continuously via pump;
• The patient requires frequent adjustment to the insulin treatment regimen based on glucose results (either finger stick or CGM readings);
• The patient has had or will have education specific to the therapeutic CGM system being requested;
• The patient and/or their caregiver can hear and view CGM alerts;
• The patient has been seen for diabetes management in past 6 months and will continue to be seen every 6 months for this purpose;
• The patient meets the CGM manufacturer’s recommendations for age range, monitoring and calibration requirements (if applicable), or has otherwise qualifying circumstances that make therapeutic CGM medically necessary.
• For continuing eligibility, all of the above must be met and Colorado Medicaid requires recertification every 6 months; be sure to schedule diabetes follow up for within 6 months of the last visit.
  

How to Order CGM by Brand

These specific instructions follow the state of Colorado example. In other states, a DME supplier or pharmacy may be the primary contact. Check each state’s Medicaid website for more information. A brand representative may be able to assist in finding the best pharmacy or DME supplier to submit. 

Private Insurance Coverage and Ordering

Commercial or private insurance plans likely have certain eligibility requirements that must be met in order to provide coverage for personal CGM. If your patient doesn’t meet them, Professional CGM may be an option for intermittent use. This resource will help you maximize the likelihood of obtaining authorization/coverage for personal CGM for commercial/private insurance.

Eligibility

Eligibility requirements may vary widely from one payer to another, or even from one plan to another for any particular payer, so specific guidance is very difficult to obtain with certainty.

Additional assistance and up-to-date resources are available at the non-profit, unaffiliated DiabetesWiseProviders Prescription Assistant Tool.

Ensure You Have Proper Documentation

• Your notes should reflect whether your patient meets their payer’s eligibility requirements for personal CGM coverage and why you feel CGM is appropriate for your patient. It may be helpful to quote and/or reference specific recommendations from the ADA Standard for Medical Care in Diabetes or its abridged version in your chart notes and/or in prior authorization requests.
• Commercial payers generally do not require a Certificate of Medical Necessity or specific order form to prescribe to a pharmacy. However, chart notes and/or prior authorization may be requested. 

Gather Information for Ordering and Insurance Authorization 

• A Prescription Will Be Required: Many EHRs support directly prescribing them as you would any medication. 
• Choose a Supplier: Some commercial insurance plans cover CGM through the pharmacy benefit, some cover it through the durable medical equipment (DME) benefit, and some will allow either.
   

How to Order CGM by Brand

Patients Without Coverage for Personal CGM

Patients who do not meet their payer's eligibility criteria for personal CGM or those who cannot afford the full cost of obtainings a personal CGM may still be able to get and benefit from CGM.

• Professional CGM – used by practices on a one-time or occasional basis for a given patient. It involves applying the CGM in the office setting and using equipment belonging to the practice. Insurance authorization is rarely required for this. Many practices find this a particularly successful path.
• Self-pay for Personal CGM – patient may be willing to pay out of pocket for device and sensors. Consider cost assistance programs for eligible patients. This may be a good option for patients who have insurance, but do not meet thier payer's eligibility criteria for personal CGM. 
• Sample or Trial of Personal CGM – Manufacturers may have voucher, sample, or trial programs for eligible patients. This may be a good option for patients who do not have insurance or have high deductible insurance plans. 

This patient handout, What if My Continuous Glucose Monitor Is Not Covered by Insurance?, can help you discuss options with your patients. Click here for the Spanish version. 

Ensure You Have Proper Documentation

The information in your chart notes should reflect why you feel that CGM is appropriate for your patient. It may be helpful to quote and/or reference the specific ADA Standard(s) in chart notes or prior authorization requests. This may be especially helpful if pursuing low or no copay options like patient assistance programs that may require your explanation of why you recommend CGM.

Gather Information for Ordering

• A Prescription Will Be Required: Many EHRs support directly prescribing them as you would any medication. 
• Forms required for cost assistance or patient assistance (if applicable)

Cost Assistance

There are various options for limiting patient out-of-pocket costs associated with CGM. Some of these include manufacturer-based samples, vouchers, copay reduction programs, and patient assistance programs. Some of these resources are listed here:

Self-pay options:Some patients may qualify for patient assistance and/or copay reduction programs.

• FreeStyle Libre program automatically limits copay to $75/month or less; if copay will be >$75, have the patient call 844-330-5535 before picking up sensors from the pharmacy
  
• Dexcom patient assistance program 
• Medtronic CGM patient assistance and Medtronic Assurance 
• Eversense patient assistance

If patients do not qualify for assistance programs, options to reduce costs include:

Coupon Programs 

• GoodRx or SingleCare can help find the lowest cost retail pharmacy in a geographic area. To use these sites, patients will need to register and can download an app to their smartphone. Both provide coupons to use at the pharmacy. To use, they will need to search by device name and ZIP code.  
• Membership warehouses with pharmacies, like Costco and Sam’s Club, often offer the lowest prices, are usually open to non-members, and may have additional significant discounts for members.

Free Trials or Samples

• Voucher for a free FreeStyle Libre2 14-day sensor 
• FreeStyle Libre 2 samples can be requested from your local representative
• 30-day trial program for Medtronic Guardian Connect system 
• Dexcom G6 sample kits (sensor and transmitter) can be requested from your local representative or online through the Hello Dexcom program