ManagedCareCGM

Continuous Glucose Monitoring

Education for Managed Care, Pharmacy, and Payer Professionals

CMS-1682R – Therapeutic CGM Category

Source: Centers for Medicare & Medicaid Services

Key Takeaway: Recognizing the value of CGM, and in response to the recent FDA approvals of CGM as a replacement for fingersticks, CMS created a benefit category for therapeutic CGMs, providing for coverage of these devices under the following conditions:

  1. The beneficiary has diabetes mellitus (Refer to the “ICD-10 Codes that are Covered” section of the LCD-related Policy Article for applicable diagnoses); and,
  2. The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and,
  3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump; and,
  4. The beneficiary’s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and,
  5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and,
  6. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.