Continuous Glucose Monitors and Insurance Coverage: What to Know

Continuous glucose monitoring (CGM) has proved a welcome development in diabetes technology. For diabetics who previously relied on blood glucose meters and daily painful fingersticks, CGM devices have revolutionized care. Now patients can get real time insight into their diabetes management plan. Insurers and healthcare providers have clearly recognized the long-term benefits and cost savings CGM devices bring. When users are able to anticipate and prevent severe hypoglycemic events, there are fewer ambulance rides, hospital admissions and expensive medical treatments.

Medicare and most major private health insurance plans now offer some level of coverage and reimbursement for CGM when prescribed by an endocrinologist or qualifying physician. These include Blue Cross Blue Shield, CIGNA, and United Healthcare, among others. More health plans are being added to the list as successful clinical trials continue and the FDA approves new real-time continuous glucose monitors. They are typically considered durable medical equipment (DME) and can be ordered through approved DME companies like Aeroflow and paid for, at least partially, by Medicare or private insurance.

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How does CGM work?

With CGM devices, patients, caregivers and healthcare providers can identify patterns in behavior, diet, and blood glucose levels that would otherwise be impossible to see. A CGM device operates via a small water resistant glucose sensor that is placed just below the surface of the skin and held in place with an adhesive patch. These sensors can be worn up to 14 days continuously, usually on the torso or upper arm, transmitting blood glucose levels to a reader every few minutes. That's a lot of data! More information equals more efficient diabetes management. Continuous glucose monitoring systems have been shown to be better at helping people with Type 1 diabetes lower their HBA1C as compared to traditional self-monitoring.

It is much easier to predict and potentially head off hypoglycemia and hyperglycemia events when you can see where blood glucose levels are headed in advance. This is especially true for those with erratic blood glucose levels, hypoglycemic unawareness, children who can't self-monitor, and others.

Additionally, users can instantly see the effects their decisions have on their glucose readings right away, and adjust their behavior accordingly. They may be less likely to splurge on dessert or skip a meal if the effects on blood sugar are immediately clear. 

These small changes can have a big impact. Some CGM devices also make it possible to share your blood glucose data with friends and family, making that sense of accountability for everyday decisions even stronger.

Medicare Coverage of CGM

Medicare has provided coverage for CGM systems since 2017, provided they are classified as ‘therapeutic’ devices, meaning users can use them to make treatment decisions. These include things like changes to exercise regimen, diet or insulin dosage. While that’s still the case, The Centers for Medicare & Medicaid Services (CMS) have recently relaxed Medicare’s other coverage criteria somewhat. Previously Medicare coverage of CGM devices was limited to patients who met the following requirements:

  • Have a diagnosis of either type 1 or type 2 diabetes
  • Use a traditional blood glucose meter and test blood sugar levels four or more times a day
  • Are treated with insulin injections or insulin pump
  • Require frequent adjustments to their insulin regimen
  • Have an in-person visit with a doctor to evaluate glycemic control and whether they meet the above criteria, as well as follow up appointments every 6 months after prescription

So what’s changed? No longer are insulin injections the only acceptable form of insulin administration for those who are covered. Now, diabetics who are treated with inhaled insulin will be eligible for coverage. Additionally, the requirement for self-testing up to four or more times a day with a fingerstick test has been removed, so diabetics who test less frequently may also be eligible.

It’s a promising development that will make therapeutic CGM devices accessible for more diabetics. Many of them may not have been eligible for Medicare coverage previously, having to pay out of pocket instead. This change took effect on July 18, 2021 and could save some people thousands of dollars per year.*

Which CGM devices are covered by Medicare?

The Dexcom G5 was one of the first of the CGM devices to be FDA approved as a therapeutic CGM in 2017, which qualified the device for Medicare coverage. As with most other technology, diabetes technology continues to evolve, and newer products have since followed suit, including those manufactured by Abbott, Medtronic, and others.

Currently, Aeroflow offers the Dexcom G6, the FreeStyle Libre 14 Day System and the FreeStyle Libre 2, all eligible for Medicare coverage. The Dexcom devices are typically worn on the skin of the torso for up to 10 days, where a water resistant sensor can measure and transmit blood glucose readings every few minutes to a reader or a smartphone app. The FreeStyle Libre is a line of continuous glucose monitors that are typically worn on the skin of the upper arm for up to 14 days. Unlike the Dexcom, the FreeStyle is a flash glucose monitoring system, meaning that while it continually measures blood glucose levels, it only transmits this to a reader when scanned. Each has its own set of unique features, alarms, and recommended age range.

If you live with type 1 or type 2 diabetes, use traditional blood glucose monitoring supplies, and require frequent changes to your insulin dosage, you may be eligible for insurance coverage. The first step is to speak with your doctor. Only your doctor will be able to determine if you meet Medicare coverage guidelines and decide which continuous glucose monitoring system is best for your diabetes care plan. Aeroflow can help coordinate with your insurance company and your healthcare provider to make sure you receive maximum benefits.

What is the average cost of a CGM device?

The out of pocket costs of CGM devices can be significant, much more than traditional blood glucose monitoring systems. Depending on what model and features you need, you will have to get prescriptions for several different items and purchase them at a retail pharmacy if you don’t have insurance coverage. These can include multiple sensors, a transmitter, and receiver. Some models work in conjunction with a smartphone you may already have, in which case you wouldn’t need a receiver, like the Dexcom G6. With the Dexcom G6 system, the average retail cost for enough transmitters and sensors for one full year is $6000, or $500 per month! That’s quite a cost prohibitive barrier for a lot of people. This new coverage change announced by Medicare, as well as the continued expansion of private insurance coverage, is good news for diabetics who could benefit from the convenience and improved outcomes possible though the use of CGM devices.

Information provided on the Aeroflow Diabetes blog is not intended as a substitute to medical advice or care. Aeroflow Diabetes recommends consulting a doctor if you are experiencing medical issues or concerns.