ManagedCareCGM

This site is intended for managed care professionals in the U.S.

This site is intended for managed care professionals in the U.S.

Professionals in Canada should visit CanadaCGM.com

Continuous Glucose Monitoring

Education for Managed Care, Pharmacy, and Payer Professionals

Coverage and Benefit Design

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Recent News

  • Effective July 18, 2021. CMS revised Medicare coverage criteria for therapeutic CGMs. Most notably, eliminating a requirement that beneficiaries use four fingerstick tests per day prior to accessing CGM. 
  • Effective immediately, Colorado Department of Health Care Policy and Financing now covers therapeutic continuous glucose monitors for adults and children with type 1 and type 2 diabetes who are insulin-dependent and meet medical necessity criteria.
  • Effective July 1, 2020, NC Medicaid coverage of therapeutic Continuous Glucose Monitoring (CGM) products will transition from the Durable Medical Equipment (DME) Program to the Outpatient Pharmacy Point of Sale Program. The products will be included on the NC Medicaid and Health Choice Preferred Drug List (PDL). The PDL Preferred therapeutic CGM products will be the Dexcom G5 and G6.
  • Effective July 15, 2020, HCSC considers long-term continuous glucose monitoring of glucose levels in interstitial fluid medically necessary in patients with diabetes (Type 1 or Type 2 DM) who are willing and able to use the device, have adequate medical supervision, and are on multiple daily doses of insulin or an insulin pump. (Reference: Medical Policy Number DME101.005)

  • Effective April 1, 2020, Blue KC will also offer coverage for Continuous Glucose Monitors (CGMs) as a pharmacy benefit. While members can continue to utilize their DME benefits instead of pharmacy benefits for CGMs, some brands may eventually no longer be available through DME suppliers. Additionally, the process of obtaining a CGM through the pharmacy is likely a more timely, convenient, and overall better member experience.

  • Effective April 20, 2020 Aetna considers the long-term (greater than 1 week) therapeutic use of continuous glucose monitoring devices medically necessary in adults aged 18 years and older with type 1 diabetes, adults with type 2 diabetes using intensive insulin regimens (multiple (3 or more) daily injections or insulin pump therapy) who are not meeting glycemic targets, and for younger persons with type 1 diabetes.

  • Effective April 1st 2020  United Health Care covers long-term CGM for individuals with type 1 or type 2 diabetes when certain criteria are met.
  • Effective April 1, 2020, therapeutic continuous glucose monitors (CGMs) will be a benefit of Texas Medicaid for individuals with type 1 or type 2 diabetes who meet medical criteria.
  • Missouri Medicaid’s Pharmacy Program will begin covering the Dexcom G6 Continuous Glucose Monitoring (CGM) System as the preferred CGM system effective April 2, 2020.


Centers for Medicare & Medicaid Services (CMS) Local Coverage Determination for Therapeutic CGMs

Source: Centers for Medicare & Medicaid Services

Key Takeaway: CMS expanded Medicare coverage for therapeutic CGMs. Most notably, eliminating a requirement that beneficiaries use four fingerstick tests per day prior to accessing CGM. According to the local coverage determination, “there is no evidence to support that frequent SMBG (≥4 times per day) as a prerequisite for initiating CGM use is predictive of improved health outcomes”.

New Coverage Criteria (Effective July 18, 2021)  

The revised LCD indicates that Medicare coverage for CGMs will be available if the beneficiary meets the following criteria:

  1. The beneficiary has diabetes mellitus; and,
  2. The beneficiary is insulin-treated with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and,
  3. The beneficiary’s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and,
  4. 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 (1-3) above are met; and,
  5. 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.

Current Eligibility Requirements for CGM Coverage Are Harmful, Costly, and Unjustified

Source: Diabetes Technology and Therapeutics

Key Takeaway: There is growing and compelling evidence that CGM coverage should be offered to all patients who can benefit from this technology regardless of diabetes type and history of SMBG use. The current restrictions, which are based on outdated evidence and questionable assessments, are not supported in the literature. Moreover, they ignore the burden frequent SMBG places on individuals. Given the growing prevalence of diabetes, the persistent preponderance of individuals with suboptimal glycemic control, and the exorbitant and largely preventable cost of diabetes complications, opinion-based constraints should not continue to supplant evidence-based clinical management.


Medicaid Coverage

*Washington, D.C.= Rx Coverage

Rx Coverage Pediatrics Only (published coverage policy)
Type 1 Type 2 No Published Coverage Policy
Type 1    

 

 

*Map updated January 12, 2021

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