Continuous glucose monitoring (CGM) is one of the best and most popular ways for those suffering with diabetes to monitor their blood sugar levels.
However, for many in the US, accessing a CGM can be difficult, with many unsure about the qualifications required to receive the monitoring system.
This brief article will inform patients and caregivers about what CGM is, how it operates, as well as specifics on the qualifying procedure for CGM with Medicare. We hope this article can help ensure that you can access this vital monitoring system to assist you with managing your diabetes (if you qualify).
So, What is Continuous Glucose Monitoring (CGM)?
Before outlining how to qualify for CGM with Medicare, it is important to understand exactly what the CGM system is and why it could be valuable in the management of blood sugar levels.
CGM is a small device that is worn under the skin to measure your glucose levels throughout the day and night.
Crucially, the CGM does not actually measure the specific glucose level in your blood, but rather the quantity of glucose that resides around your body cells.
Although the CGM does provide real-time data, there can be delays of accurate assessment after eating or exercising.
There are two known types of CGM currently available:
- Real-time: This allows the patients the capacity to check their glucose levels at any time of the day as well as being able to download the results.
- Retrospective: This allows a download facility of glucose level results ONLY rather than being able to make real-time assessments.
How does the CGM operate?
The CGM is broken down into three separate parts:
- The sensor is a tiny piece that sits underneath your skin to measure glucose levels
- The transmitter is fitted to the sensor and transmits the information to the external display device
- The external display device may be a completely separate device or a pump
Where can I get more information on CGM?
There is plenty of great advice out there.
For specific information about the enrollment of CGM across different health care plans, you will have to examine specific CGM policies.
How do I qualify for CGM with Medicare?
Although at times navigating the Medicare’s qualification for CGM can seem a bit complicated, in truth, it is quite straightforward to understand.
To help you simplify it, here’s our take—
To qualify for CGM with Medicare, there are some key criteria patients must qualify for, these are:
- The patient must have Diabetes Mellitus
- The last face-to-face contact with a physician was within the last 6 months
- The patient needs to be testing blood sugar levels 4 times per day. For those on a new testing routine, you must provide at least two weeks worth of logs to demonstrate the patient is testing 4 times a day
- The patient must be injecting insulin a minimum of 3 times a day or they must be using an insulin pump. If you are using a V-Go device, this is also considered an insulin pump by Medicare
- The visit notes (from a physician) must demonstrate that the patient is on a sliding or corrective scale, which means they are adjusting the levels of insulin for injections based on glucose tests
- If a patient qualifies for CGM with Medicare, they must have a face-to-face visit with a physician at least once every 6 months to demonstrate a continual use of the equipment through official documentation.
There are also three key exemptions which will prevent you from accessing CGM with Medicare, these are:
- Use of the receiver: If you have initially qualified for CGM with Medicare and have synced up the device with your smartphone or tablet and are not using the receiver, Medicare will deny any future claim of benefits using CGM
- Dialysis: Unfortunately, as the FDA has not supported the use of CGM with patients who are on dialysis, Medicare does not cover patients for using CGM while on dialysis.
- Pacemakers or other implanted electronic devices: As the CGM requires the implanting of a device, a key qualification is that the patient does not have any other electronic implanted devices. Although there is no official ban on patients with existing devices accessing CGM, it is generally not recommended and will not be covered by Medicare unless there is a waiver that is signed by both the patient and the physician.
In addition to the three exemptions detailed above, poor patient communication is the most common reason why patients are unable to qualify for CGM with Medicare.
Here are some tips to ensure you don’t make the common mistakes made by others:
- Always review your notes. Ultimately, you are the person who is most aware of how many tests you are doing, the amount of insulin you are injecting or the type of plan you are on.
If there is any contradiction between your existing treatment and what is documented, this could lead to you failing to qualify for CGM with Medicare. This is particularly why it is important for you to make sure you’re on top of your daily regimen.
- Ensure your insulin injections reflect the blood sugar tests. After qualifying for the CGM with Medicare, you must follow the correct procedure when it comes to administering the correct dosage of insulin.
One of the key benefits of the CGM is that it provides you with accurate information on the amount of insulin you should inject. If the physician changes the dosage without any reference to the CGM tests or documented evidence, Medicare will not insure you.
Hopefully, this article has given you all the essential information about what CGM is and the steps you need to follow to qualify to have a system with Medicare.
Remember, thousands of people each year are denied because of issues in their communication with Medicare, therefore take time to review and double-check your documentation before submitting your paperwork.