Important Update: Effective 4/16/23
Patients can qualify if simply treated with insulin (instead of prior requirement for 3+ daily doses of insulin) OR with a history of “problematic hypoglycemia*” even if not treated with insulin.

In order to be eligible for Medicare coverage of personal CGM, the following requirements must be met:

• The patient has a diagnosis of diabetes; and
• The patient is treated with insulin OR is not treated with insulin but has a history of problematic hypoglycemia*; and
• CGM is being prescribed to improve glycemic control; and
• The patient has been seen for diabetes management in the past 6 months (in-person or Medicare-approved telehealth); and
• The patient requires adjustment to the treatment regimen based on glucose results (either finger stick or CGM readings), unless results tend to be in the target range.
• For continuing eligibility, all of the above must be met and Medicare requires that the treating practitioner have a visit with the patient to assess the CGM regimen and diabetes treatment plan at least every 6 months following initial CGM prescription.

*Problematic hypoglycemia is defined by the CMS criteria as either of the following:

• Recurrent (more than one) level 2 hypoglycemic events (glucose <54 mg/dL), as evidenced in the medical record by
  • glucose <54 mg/dL, or
  • treating practitioner classifies hypoglycemia as level 2 event, or
  • patient’s glucose testing log shows glucose <54 mg/dL and is incorporated into the medical record

• At least one level 3 hypoglycemic event (glucose <54 mg/dL and required third party assistance to treat hypoglycemia), as evidenced in the medical record by
  • notation of third party assistance for treatment of the event, AND
  • at least one of the following:
    • glucose <54 mg/dL, or
    • treating practitioner classifies hypoglycemia as level 3 event, or
    • patient’s glucose testing log shows glucose <54 mg/dL and is incorporated into the medical record

 

Chart note example: The following can be added to your chart notes for patients meeting Medicare’s eligibility criteria. You can copy/paste, add to your EHR’s macro library (sometimes called smartphrases, dotphrases, or auto-text), and/or modify as needed:

• This patient has a diagnosis of diabetes; is treated with insulin; requires frequent adjustment of the insulin treatment regimen based on glucose results; and has been personally seen to evaluate their diabetes management within the past 6 months.

A prescription or order will be required. Many EHRs support directly prescribing/ordering them as you would any medication. Ordering through your EHR will make it easier to reorder in the future. Although patients may choose to use their smartphone, they must use it in conjunction with a reader in order for Medicare coverage of a CGM. Smart-devices are not covered by Medicare as they do not meet the definition of DME.

• To order Dexcom, complete the Dexcom Order Form. You must check off the box to order the receiver even if the patient will also use their smartphone.
• Fax the Order and chart notes to ASPN Pharmacy: (866)- 879-8150

OR

• Complete the Acentus Standard Written Order Form and fax patient demographics, completed form, and chart notes to Acentus: - 1-866-695-2183

• To order the Freestyle Libre 2, Libre 2 plus, or Libre 3, complete the Medicare Standard Written Order. Please note that even though this order asks for the prescribed glucose tests per day, this is no longer a Medicare requirement.
• Fax the Order and chart notes to a Freestyle Libre DME supplier listed on the Medicare Standard Written Order link above.

OR

• Complete the Acentus Standard Written Order Form and fax patient demographics, completed form, and chart notes to Acentus: 1-866-695-2183

• For Medtronic, visit their healthcare professional website for their most current resources: https://www.medtronic.com/us-en/healthcare-professionals/products/diabetes/continuous-glucose-monitoring-systems.html

• Eversense requires that the transmitter be implanted; it is recommended that you seek preauthorization for the implantation procedure before ordering. To become an Eversense provider and to pursue information on ordering, visit https://www.ascensiadiabetes.com/eversense/become-a-provider/#get-started-form.

Additional assistance and up to date resources can be found here, a prescription assistance tool at the non-profit, unaffiliated website DiabetesWiseProviders (https://providers.diabeteswise.org/#/en/prescriptions)

Dexcom:

Aaron West - Territory Business Manager
Email: aaron.west@dexcom.com
Can help with most Dexcom items, including Hello Dexcom samples.

Terra Thompson, RN, CDE - Clinical Account Manager
Email: terra.thompson@dexcom.com
Can help with all training and Clarity.

Kevin Stroud - District Business Manager
Email: Kstroud@dexcom.com

Can assist with urgent items.

Abbott Freestyle Libre:

Rick Burke
Phone: 408-569-5588
Email: Rick.Burke@abbott.com

 

 

 

 

• Professional CGM
• Sample of Personal CGM
• Self-pay for Personal CGM, with or without various coupons, copay reduction programs, and/or vouchers; over the counter CGMs are also a more affordable option that doesn't require a prescription
• If they haven’t been seen for diabetes management in the past 6 months, have them seen for this purpose (in-person or via telehealth).
• Membership warehouses with pharmacies, like Costco and Sam’s Club, often offer the lowest prices, are usually open to non-members, and may have additional significant discounts for members.