Yes. Under certain conditions, Medicare will cover a continuous glucose monitor (CGM) - and Medicare specifically notes:
“If your doctor [primary care physician] determines that you meet all the coverage requirements, Medicare covers continuous glucose monitors and related supplies [(sensors and transmitters)] for making diabetes treatment decisions, (like changes in diet and insulin dosage).”
What is a CGM?
A Continuous Glucose Monitor automatically measures the level of glucose in a person and indicates whether the glucose level is rising or falling. More importantly, the CGM will alert the user when their glucose falls below a safe level. The CGM can also show how a person's glucose levels change over time so a CGM user can better understand how their lifestyle (diet and exercise) affects their glucose level. A CGM works by having a very small (painless) sensor placed under the skin that monitors glucose levels and transmits this information back to a reader or a smartphone.
What is required to get coverage for a CGM?
Medicare notes that the requirements for coverage of a CGM include the need to have a prescription from your primary care physician based on your need to:
- Frequently check your blood sugar or adjustment to insulin treatment based on glucose results (*4 or more times a day*), and
- Either use an insulin pump or get 3 or more insulin injections per day.
You must also make in-person visits with your doctor for diabetes management every 6 months - or meet by a Medicare-approved telehealth visit).
* 2021 Changes to CGM Coverage Requirement
On July 18, 2021, the prerequisite for a CGM of "[f]our times or more per day testing with a blood glucose monitor" was removed. However, the official CMS site (as of 06/20/23) and corresponding diabetic guidance (dated June 2023) still shows the requirement for 4 or more times a day monitoring. (compare https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33822 Revision 8 to https://www.medicare.gov/Pubs/pdf/11022-Medicare-Diabetes-Coverage.pdf)
As noted by the Juvenile Diabetes Research Foundation (JDRF):
"Effective on July 18, 2021, people with diabetes will no longer need to
prove that they are testing their blood sugar at least four times per
day with a blood glucose meter to get initial Medicare coverage for a
CGM device." (https://www.jdrf.org/blog/2021/07/23/on-medicare-accessing-cgms-just-got-easier/)
The cost of a CGM
If you meet the requirements for a Continuous Glucose Monitor, the cost of the CGM may depend on your healthcare coverage.
- If you have original Medicare Part B, the CGM will be covered as Durable Medical Equipment (DME) with 20% cost sharing (you pay 20% of the cost) after meeting the Part B deductible.
- If you are eligible for your state Medicaid program, the coverage requirements for a CGM will depend on your state - and you can contact a local Medicaid office for more details.
- If you are enrolled in a Medicare Advantage plan (MA or MAPD), you can speak with your plan's Member Services department for more information about CGM coverage. You may find that the Medicare Advantage plan provides coverage that is similar to the original Medicare Durable Medial Equipment 20% coinsurance.
What if you cannot meet the CGM eligibility requirements?
There may still be other ways to benefit from a CGM. As noted by the American Academy of Family Physicians Foundation (AAFP), you still may be able to use a:
(1) Professional CGM (owned by the professional healthcare practice and available for use),
(2) Self-pay for a CGM, or
(3) Sample or Trial CGM (possibly available from the CGM manufacturer or GoodRx.com or SingleCare.com).
You can read more here:
(https://www.aafp.org/content/dam/AAFP/documents/patient_care/nrn/no-personal-cgm-coverage-handout.pdf
https://www.aafp.org/family-physician/patient-care/care-resources/continuous-glucose-monitoring.html#)
To learn more . . .
To learn more about the coverage of a Continuous Glucose Monitor, you can reach a Medicare representative by calling toll-free
1-800-633-4227 (1-800-Medicare) - TTY users can call 1-877-486-2048.
Once connected, please explain your situation to a Medicare
representative and ask the representative to help you learn more about
the coverage of a continuous glucose meter.
Sources include:
https://www.medicare.gov/coverage/therapeutic-continuous-glucose-monitors
https://www.medicare.gov/coverage/blood-sugar-monitors
https://www.medicare.gov/Pubs/pdf/11022-Medicare-Diabetes-Coverage.pdf
*(June 2023 "The [CGM] requirements include the need to:
Frequently check your blood sugar (4 or more times a day), and . . ..")
https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33822
*(see Revision 8 - R8 07/18/21 "Removed: Four times or more per day testing with blood glucose monitor as prerequisite for CGM coverage")
https://www.jdrf.org/blog/2021/07/23/on-medicare-accessing-cgms-just-got-easier/
https://www.aafp.org/family-physician/patient-care/care-resources/continuous-glucose-monitoring.html