DME MACs Finalize Expanded CGM Coverage

An LCD update and policy article make the expanded coverage for continuous glucose monitors effective before the end of the Covid-19 PHE.

• By David Kopf
• Mar 02, 2023

The DME MACs have released an expected LCD update and policy article that finalize expanded coverage for continuous glucose monitors for diabetes patients before the end of the Covid-19 public health emergency.

The DME MACs set the effective date for the updated LCD and policy article on April 16, which is nearly four weeks before the May 11 end to the PHE that a Biden administration policy statement said it intends to implement. The American Association for Homecare welcomed the advance effective date.

“AAHomecare thanks the DME MACs for finalizing the CGM coverage prior to the end of the PHE,” the association noted in a public statement. “This addresses concerns with CGM patients that qualified under the PHE waivers but would not have under the currently effective LCD.”

The association also highlighted these coverage guidelines from the updated LCD and policy article:

To be eligible for coverage of a CGM and related supplies, the beneficiary must meet all of the following initial coverage criteria (1)-(5):

• The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses); and,
• The beneficiary’s treating practitioner has concluded that the beneficiary (or beneficiary’s caregiver) has sufficient training using the CGM prescribed as evidenced by providing a prescription; and,
• The CGM is prescribed in accordance with its FDA indications for use; and,
• The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the criteria below:
• The beneficiary is insulin-treated; or,
• The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the following (see the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section of the LCD-related Policy Article (A52464)):
• Recurrent (more than one) level 2 hypoglycemic events (glucose <54mg/dL (3.0mmol/L)) that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan; or,
• A history of one level 3 hypoglycemic event (glucose <54mg/dL (3.0mmol/L)) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia
• Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare-approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria (1)-(4) above are met.

The DME MACs also published their responses to the public comments received during the open comment period for the proposed glucose monitors LCD.