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Medicare Coverage Criteria Evolution
Medicare CGM coverage has evolved significantly, expanding access from intensive insulin users to broader diabetic populations.
Medicare Coverage Criteria Evolution
A History of Expanding Access
Medicare's CGM coverage has evolved dramatically over the past decade.
Key Milestones
Early Days
- CGM initially not covered by Medicare
- Considered "investigational" or not medically necessary
Initial Coverage (2017)
- CGM covered for intensive insulin users only
- Required 4+ daily insulin injections or pump use
- Therapeutic CGM (real-time) covered under DME
2023 Update (LCD L33822)
Major expansion removing the "intensive" insulin requirement:
- All insulin-treated diabetics now qualify
- Non-insulin users with recurrent hypoglycemia qualify
- Simplified documentation requirements
Current Requirements
To qualify for Medicare CGM coverage:
- Diabetes diagnosis
- One of:
- Treatment with insulin, OR
- Documented recurrent Level 2/3 hypoglycemia
- Physician prescription and oversight
Future Directions
Advocacy continues for:
- Coverage of OTC CGMs
- Reduced prior authorization requirements
- Coverage for pre-diabetes prevention