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Insurance Coverage and Medicare Criteria
CGM insurance coverage has expanded significantly following the CMS 2023 update, with Medicare, commercial insurance, and Medicaid all providing various coverage options.
Insurance Coverage and Medicare Criteria
Expanded Coverage
Insurance coverage for Continuous Glucose Monitors has expanded significantly following the CMS 2023 update (LCD L33822).
Medicare Coverage
Who Qualifies
Medicare now covers:
- Any beneficiary with diabetes treated with insulin (no longer requires "intensive" therapy)
- Non-insulin users with documented recurrent Level 2 or Level 3 hypoglycemia
Benefit Structure
Devices are covered under the DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) benefit.
Commercial Insurance
Trend Toward Pharmacy Benefits
Many commercial insurers are shifting CGM coverage from Medical/DME benefits to Pharmacy Benefits, which:
- Simplifies access via retail pharmacies
- Offers more predictable copays
- Uses real-time adjudication
Prior Authorization
Most plans mirror CMS medical necessity criteria but may impose Prior Authorization (PA) requirements.
Medicaid
Coverage varies significantly by state:
- Near-universal coverage for Type 1 diabetes
- Growing coverage for Type 2 diabetes
Reimbursement Coding
Device and Supplies
- HCPCS E2103: CGM Receiver
- HCPCS A4239: Monthly Supplies
Professional Services
- CPT 95251: Monthly analysis and interpretation of CGM data