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.