Dexcom CGM Now Eligible for Reimbursement Under Medicare
Dexcom CGM Now Eligible for Reimbursement Under Medicare
After a few false starts this year, Medicare has finally established a path for reimbursement for therapeutic continuous glucose monitoring (CGM) with the Dexcom G5 CGM system. If you’ve been waiting for Medicare approval to get started with CGM, this is great news, especially if you’re getting tired of multiple finger-sticks.
Here’s what you need to know about getting this new medical technology covered:
What is continuous glucose monitoring?
If you’re currently using a blood glucose monitor to track your glucose, you know that it provides a single reading—a snapshot of your blood sugar at that moment in time. You don’t know if your glucose is coming down, going up, or stable over a period of time.
Continuous glucose monitoring is exactly what it sounds like: A system that lets you track your blood glucose continuously, around the clock, so you take action to better manage your diabetes. Currently, the Dexcom G5 CGM is the only system that meets the Medicare criteria for reimbursement.
The Dexcom system uses a tiny sensor to measure blood glucose just beneath the skin. The sensor is attached to a transmitter that sends the results to a hand-held device that displays your numbers in real time. The sensor is worn on the abdomen; you can exercise and shower with it. In fact, most people forget they are wearing it. The sensors are disposable—you replace them about every seven days.
The system takes a glucose reading every five minutes, or 288 times a day. You can easily see if your numbers are trending up or down, and how fast they are moving. You and your doctor can even set a normal range and program the device to alert you when your glucose moves outside that range. You can also set the device to warn you if your numbers get high or low while you’re sleeping at night.
Studies have shown that people who use the Dexcom CGM system reduce their A1c by an average of 1.3%, because they have the real-time information they need to make proactive diabetes treatment decisions and avoid those extreme highs and lows.
Of course, CGM doesn’t eliminate the need for finger-sticks altogether; the device needs to be calibrated with a finger-stick twice a day. But if you’re one of those people who are used to multiple finger-sticks every day, the twice-daily calibration is a breeze.
Who is eligible for reimbursement for the Dexcom CGM system?
The rules for eligibility are pretty straightforward. You must have type 1 or type 2 DM and all of the following must be true:
• You test your blood glucose at home at least four or more times per day.
• You need at least three daily insulin injections, or use an insulin pump.
• You frequently adjust your insulin treatment based on the results of your glucose monitoring.
• You’ve had an in-person visit with your doctor no more than six months
before the date he or she orders the Dexcom system for you.
• You see your doctor at least once every six months after getting the device
to make sure you’re adhering to the treatment plan and CGM is working well for you.
It’s important to note that even though the Dexcom CGM system can work with an app on your smartphone or other mobile device, Medicare will only cover the system if you use it with the handheld receiver designed especially for the system.
How does Medicare cover the Dexcom G5 CGM system?
Medicare treats the Dexcom CGM system as it does any other durable medical equipment, or DME. DME is a category of equipment and supplies that includes everything from wheelchairs to oxygen tanks to home blood glucose monitors.
If you have Original Medicare (Part A and Part B), the Dexcom system and all associated covered supplies are covered at 80% of the allowable charges, after you meet any applicable Part B deductible. If you have Medigap coverage, you may be able to get the system with no out-of-pocket costs.
Medicare Advantage plans may have different coverage rules for durable medical equipment. By law, they must offer the same coverage as Original Medicare at a minimum, but some plans may have a different copayment or coinsurance amount for DME. If you have Medicare Advantage, check your plan benefits to see what you’ll pay out of pocket for the Dexcom G5 system.
Note, however, that if you choose the Dexcom CGM system, Medicare will cover that in place of a standard home blood glucose monitor. Medicare will only cover one type of glucose monitoring device at a time, so any claims for a standard blood glucose monitor and related supplies will be denied if you are using CGM.
Now that Medicare offers better coverage for continuous glucose monitoring,
your doctor will have more choices in helping you to control your diabetes.
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Thank You to Our Guest Blog Writer:
Danielle Kunkle
Co-Founder of Boomer Benefits
www.boomerbenefits.com
Danielle Kunkle is the co-founder of Boomer Benefits, an insurance agency specializing in Medicare-related insurance products.
They help baby boomers New to Medicare learn about their benefits and coverage options across 47 states.
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