Continuous Glucose Monitorning (CGM) Sensors
Medicare Coverage Criteria for CGM
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:
A. The beneficiary is insulin-treated; or,
B. The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the following:
1. Beneficiaries with non-insulin treated diabetes and a history of recurrent (more than one) level 2 hypoglycemic events
a. The treating practitioner must document at least one of the following in the medical record for each event:
i. The glucose values for the qualifying event(s) (glucose <54mg/dL (3.0mmol/L)); or,
ii. Classification of the hypoglycemic episode(s) as level 2 event(s); or,
iii. Incorporate a copy of the beneficiary’s BGM testing log into the medical record reflecting the specific qualifying events (glucose <54mg/dL (3.0mmol/L)); and,
b. Documentation of more than one previous medication adjustment and/or modification to the treatment plan (such as raising A1c targets) prior to the most recent level two event.
2.Beneficiaries with non-insulin treated diabetes and a history of at least one level 3 hypoglycemic event
a. The treating practitioner must document at least one of the following in the medical record:
i: The glucose value for the qualifying event (glucose <54mg/dL (3.0mmol/L)); or,
ii. Classification of the hypoglycemic episode as level 3 event; or,
iii. Incorporate a copy of the beneficiary’s BGM testing log into the medical record reflecting the specific qualifying event (glucose <54mg/dL (3.0mmol/L)); and,
b. An indication in the medical record that the beneficiary required third party assistance for treatment.
5. 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.
