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Medicare Coverage for CGM? Who knows!

Medicare Coverage for CGM? Who knows!

At the beginning of the year, there was a lot of news floating around the diabetic communities that Medicare would start providing coverage for continuous glucose monitoring systems. It was a huge day for type 1s because those CGM devices don’t come cheap, and having coverage from Medicare could take a lot of the pressure off families to pay for those expenses out of pocket. Unfortunately, we may have celebrated too soon.

Through the years, there has been a huge push for law makers to make some serious changes in how they handle diabetic supplies and the coverage that’s offered through Medicare. There has been years and years of advocacy by various groups. One of the biggest groups was JDRF, who has been focused on making serious ramifications to their rulings. JDRF was one of the groups that participated in the FDA Advisory Committee meeting that revolved around the Dexcom G5. In this advocacy meeting, there were over 35 patients, and they told their testimonies about how the CGM has changed their lives. They’ve also created two massive petitions which included over 10,000 signatures of people with diabetes and their families. All of this work played a huge role in getting the attention that the subject deserves.

It all sounds great, but even after the change, there still is not the coverage from Medicare that we thought it would get. We’ve taken the first steps, but there is still a long way to go.

The problem was that of the CGM devices that were approved by the FDA to deliver insulin, none of them were considered durable medical equipment, which is one of the areas that Medicare covers. Recently, the Dexcom G5 received the approval that they need to deliver insulin, but it was categorized as an “adjunctive” technology, which meant that it was necessary for the health of people with diabetes. After the ruling though, the CMS re-evaluated the classification and decided that Dexcom G5 is a therapeutic device, which means it can be considered a durable medical equipment, which means Medicare covers it, right?

Not exactly. Transitioning from theoretical to actual coverage is proving to be difficult for a lot of type 1 diabetics. The problem is that very few people understand that these devices are considered necessary and that it’s being evaluated on a case-by-case scenario. That’s means that Medicare might by for one patient to get a CGM, while it might refuse another to get the same device. As you can imagine, this has caused quite an uproar from the diabetic community.

While all of this has been going on, Dexcom has been communication with the public, and they released a statement saying they are still waiting on a clarification from CMS to show what documents are needed for a patient to get the CGM coverage. “We are focused on finalizing this process with CMS to ensure our current and new customers get what they need. We are working to resolve this situation as quickly as we can and hope to have it all resolved by summer.”

Since the initially rule change, there has been a little clarification on what they were going to deem as necessary. A notice said that anyone with type 1 diabetes or even those with type 2, who require insulin therapy and blood glucose tests at least four times a day would be eligible for Medicare coverage for their CGM.

It seems like we are slowly making our way to sufficient coverage for Medicare enrollees with diabetes, but there are still a lot of hurdles that we have to get over before we’re getting the coverage that we need. For example, there is still no word on how many tests strips will be covered for anyone getting a CGM.

CGMs And Healthcare

It can be a confusing roller coaster trying to keep up with all of the rules changes and coverage restrictions that are placed on Medicare and other health care programs, but one of the most important things to realize is that you shouldn’t let these rules keep you from getting the health treatments that you need.

Your health is the most important thing that you can ever focus on, especially as a person with diabetes. Regardless of which type of diabetes that you have, or how long that you’ve had it, it’s vital that you’re getting your condition the attention that it needs.

If you’re having any problems paying for the equipment or treatments that you need, please contact us. There are plenty of programs that are willing to assist you in getting the coverage that you need. Every year, countless diabetics are not getting the medications and CGMs that they need because of finances, and that’s one of the worst things that could ever happen.

MedicareWallet.com is an unbiased, online resource for individuals turning 65 or already on Medicare. Our utmost goal is to provide information in a way that is user-focused, informative and ethical. With a combined 40 years of experience in the Medicare market, we can answer any questions about Medicare and Medigap insurance. Feel free to reach out to us at 800.376.0824 or by email at[email protected].com.

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