Medicare expands coverage of continuous glucose monitoring

The Centers for Medicare & Medicaid Services (CMS) has expanded coverage for continuous glucose monitors (CGM) for services provided on or after April 16. CGM services are now covered for all patients with diabetes who are treated with insulin or who have hypoglycemia and meet at least one of the following specifications:

• 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.

An in-person or Medicare-approved telehealth visit with the prescribing physician is required within six months of starting CGM.

Previously, CMS required the beneficiary to be insulin-treated with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) pump.

This coverage change includes type 1, type 2, and gestational diabetes. CMS also removed the coverage requirement that the beneficiary’s insulin treatment regimen needs frequent adjustments based on blood glucose monitor or CGM testing results.

Physicians should still plan to document adherence to the CGM regimen and diabetes treatment plan, but this represents a reduction of documentation challenges. It also makes for easier prescribing of CGM devices, which must be done in accordance with the Food and Drug Administration’s indication for use. Additional information on the CGM coverage criteria can be accessed here.

— Kent Moore, AAFP Senior Strategist for Physician Payment

Posted on May 1, 2023