Recent Changes to Medicare CGM Coverage: What You Need to Know

Diabetes patients now benefit from Continuous Glucose Monitors (CGMs), giving them new motivation. These devices track blood sugar levels all day long, giving people the power to make better choices about their health. Doctors can see patterns and help patients avoid dangerous blood sugar drops or spikes. Medicare patients who get CGMs often see big improvements in how they feel every day.

Getting CGM coverage through Medicare used to be hard. The rules were strict and confusing. Many people who needed these devices could not get them. Medicare saw this problem and decided to make changes. In 2023 and 2024, new rules came out that help more people get CGMs.

Medicare wants to give all qualified patients access to the best diabetes tools available. The new changes show that Medicare understands how important CGMs are for keeping people healthy. These updates remove old barriers and create new ways for patients to get approved.

Expanded Eligibility: More Beneficiaries Can Access CGMs

Inclusion of All Insulin-Treated Individuals

Before April 2023, Medicare had very strict rules about who could get CGMs. Only people who took insulin many times per day could qualify. People who used insulin pumps also qualified. But many insulin users were left out. Some people only take long-acting insulin once a day. A few people are advised to take their insulin only a few times per week. These patients could not get CGM coverage even though they needed it.

Medicare changed this rule on April 16, 2023. Now any person who takes insulin can get a CGM covered. It doesn’t make a difference which type of insulin you use and how often you take it. If your doctor prescribes insulin for your diabetes, you can qualify for CGM coverage. This change helps thousands of Medicare patients who were excluded before.

Coverage for Non-Insulin Users with Hypoglycemia

Medicare made an even bigger change for people who do not use insulin. Some diabetes patients use other medicines that might result in their blood sugar dropping rapidly. If blood sugar drops below normal, it is a medical emergency. They are known as Level 3 hypoglycemia. The individual’s blood sugar drops under 54 mg/dL, so they need support from a helper.

Medicare provides CGMs for people experiencing at least one Level 3 hypoglycemic event. Being found eligible for subsidies does not require using insulin. This rule change shows that Medicare understands the real dangers of low blood sugar. CGMs can tell people when their blood sugar may be going very low.

Eliminating Fingerstick Testing Requirements: A Step Toward Modernization

Old Medicare rules required people to test their blood sugar with fingersticks many times per day. Patients had to poke their fingers and test drops of blood. This was painful and inconvenient. Medicare required this testing to prove that people really needed CGMs.

Modern CGMs are much more accurate than the early versions. They give reliable readings without the need for constant fingerstick tests. Medicare recognized this improvement and removed the fingerstick requirement. Patients no longer need to prove they test their blood sugar frequently to qualify for CGM coverage.

This change makes life easier for diabetes patients. Fingerstick testing hurts and leaves marks on fingers. Some people avoided testing because of the pain. Now these barriers are gone. People can get CGMs based on their medical need, not on how often they are willing to poke their fingers.

Telehealth Evaluations: Increasing Access and Convenience

The COVID-19 pandemic changed how people receive medical care. Many appointments moved online through telehealth visits. This worked so well that Medicare decided to keep telehealth options for CGM evaluations even after the pandemic.

Before this change, patients had to visit their doctor’s office in person to get approved for CGM coverage. This created problems for many people. Some patients live far from their doctors. Others have trouble getting transportation. Rural patients often drive hours to see specialists.

Doctors can now check if patients are eligible for CGM without the patient having to go in person. They are able to have their appointments remotely at home through a computer or smart device. It speeds up and simplifies the process for all concerned.

Prior Authorization: What You Need to Know Starting September 2024

Starting September 1, 2024, some Medicare Advantage plans added new requirements for CGM coverage. UnitedHealthcare Medicare Advantage plans now require prior authorization for most CGM requests. This means doctors must get approval before patients can receive their CGMs.

Key points regarding this update:

• People with Type 1 diabetes do not need prior authorization
• All other diabetes types require prior authorization
• Doctors must submit medical records that prove the patient needs a CGM
• The documentation must follow CMS’s Local Coverage Determination L33822
• People switching plans get 90 days to avoid coverage gaps

This change aims to control costs while ensuring CGMs go to patients who really need them. Getting coverage for a CGM may take longer because prior authorization is needed. To save time, patients can talk with their doctor in advance to prepare all required medical records.

Device Requirements and Coverage Specifics

Medicare will pay for CGM devices that fulfill specific criteria. The Food and Drug Administration must approve all covered CGMs. The devices must also qualify as durable medical equipment under Medicare rules.

Medicare covers CGM systems that include:

• A separate receiver device, or
• An insulin pump that shows glucose readings and qualifies as durable medical equipment

Many CGMs can send data to smartphones and tablets. While this feature is useful, Medicare requires that patients have access to a dedicated receiver. Medicare coverage includes all necessary CGM supplies. This means replacement sensors, transmitters, and other parts are covered.

How to Navigate and Maximize Benefits Under the New Medicare CGM Policies

1. Consult Regularly With Your Healthcare Provider

Initial and regular visits with your doctor are very important for using a CGM effectively. The medical team has to study your glucose readings and search for recurring trends. Schedule follow-up appointments every few months to discuss your CGM data.

2. Engage in Diabetes Education Programs

Learning how to use CGM data effectively takes time and practice. Many healthcare systems offer classes specifically about CGM technology. These programs teach you how to read glucose trends and respond to alerts.

3. Use Compatible Devices to Track and Share Data

Most modern CGMs work with smartphone apps that enhance their usefulness. These apps can store months of glucose data and create detailed reports. You can share these reports with your healthcare team before appointments.

4. Keep Documentation Ready for Prior Authorization

When a Medicare Advantage plan needs you to get prior authorization, have your medical records handy in advance. Talk to the staff at your doctor’s office to find out what Medicare asks for.

5. Stay Informed on Policy Updates

Medicare addresses changes as new findings from research and advances in technology happen. Receive newsletters from diabetes groups to learn about policy changes.

Frequently Asked Questions (FAQs)

Q1: Am I Eligible For Medicare CGM Coverage If I Only Take Basal Insulin?

Yes. Medicare now covers CGMs for all people who take any type of insulin. Basal insulin users qualify just like people who take rapid-acting insulin multiple times per day.

Q2: Can I Get A CGM Covered If I Do Not Use Insulin But Have Low Blood Sugar Episodes?

CGMs are covered by Medicare for people who have had serious low blood sugar and needed the support of others. Insulin use is not part of the requirements for this kind of health insurance.

Q3: Is Prior Authorization Required For All Medicare Beneficiaries?

No. Prior authorization starting September 2024 only applies to certain UnitedHealthcare Medicare Advantage plans. People with Type 1 diabetes are exempt from prior authorization requirements.

Q4: Can Telehealth Visits Count Toward CGM Coverage Evaluations?

You can have a telehealth meeting with Medicare to evaluate who qualifies for CGM. Because of this, people living in rural areas can handle basic medical tasks more easily.

Q5: Do I Still Need To Perform Fingerstick Tests To Qualify For Or Use A CGM?

No. Medicare removed the requirement for frequent fingerstick testing. You do not have to show test results to receive coverage for a CGM

Conclusion

Medicare’s simplified coverage for diabetes is a major improvement for people with the condition. This offers patients fresh opportunities to use technologies that can greatly change their lives. More people can now get CGMs covered, and the approval process is simpler and more convenient.

The expanded eligibility rules help both insulin users and people with severe hypoglycemia problems. The removal of fingerstick requirements eliminates a painful barrier. Telehealth evaluations make the approval process accessible to everyone. These improvements show that Medicare is committed to supporting modern diabetes management.

If you or someone you care about manages diabetes and wants to understand how these Medicare changes affect CGM access, Healify Now stands ready to provide guidance throughout the entire process. Our experienced care team answers questions, helps navigate insurance requirements, and supports patients in adding CGM technology to their daily health management routine.

Contact Healify Now today for a personalized consultation. Our specialists are prepared to explain Medicare’s updated CGM policies, evaluate your eligibility status, and help you begin your path toward better glucose management. Visit healifynow.com or call us to discover more.

Evelyn Brown