What’s Wrong with This Picture? A Critical Review of Current Centers for Medicare & Medicaid Services Coverage Criteria for Continuous Glucose Monitoring
Source: Diabetes Technology & Therapeutics
Key Takeaway: Current CMS eligibility criteria for CGM coverage is limited and inconsistent relative to current scientific evidence. To expand access to all individuals who would benefit from CGM, it is recommended that CMS modify its eligibility requirements to include all Medicare beneficiaries who meet any one of the first four criteria below, and who also meet the fifth criterion:
| Criterion | Supporting Evidence |
| 1. Diagnosed with T1D. | CGM use confers: Significant reductions in • HbA1c • severe hypoglycemia events • %TBR • diabetes-related hospitalizations Significant improvements in |
| 2. Diagnosed with T2D and treated with any insulin regimen. | CGM use confers: Significant reductions in • HbA1c • %TBR • diabetes-related hospitalizations Significant increases in %TIR |
| 3. Diagnosed with T2D and documented problematic hypoglycemia regardless of diabetes therapy. This would include a history of at least one of the following conditions: Level 2 (moderate) hypoglycemia, characterized by glucose levels ≤54 mg/dL; Level 3 (severe) hypoglycemia, characterized by physical/mental dysfunction requiring third-party assistance; or nocturnal hypoglycemia | CGM use confers: Significant reductions in • diabetes-related hospitalizations, including severe hypoglycemia events • hypoglycemia fear and Increased patient confidence in avoiding/treating hypoglycemia, thereby supporting treatment adherence |
| 4. Advanced CKD at risk for hypoglycemia. | CGM use facilitates: • More frequent treatment changes and improved glycemic control without increased risk of hypoglycemia • Effective monitoring and managing of glycemic levels in nondiabetes patients with ESRD undergoing dialysis |
| 5. In-person or telemedicine consultation with the prescribing health care provider before CGM initiation and every 6 months thereafter while continuing CGM therapy. (Coverage for telemedicine consults should be available for all patients regardless of geographic location.) | Use of telemedicine consults: Significantly reduces • the incidence of severe hypoglycemia events • diabetes-related distress Significantly improves medication adherence Use of downloaded CGM data into standardized reports: |
Click here to view CGM Payer Insights Sheet with key findings.
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