FAQs on CGM Coverage Criteria Changes in Medicare

If you or your patients have Medicare, new changes allow greater access to a CGM devices. Medicare beneficiaries with diabetes may be eligible if they:

1. Have diabetes 
   and
2. Your health care provider concludes you (or your caregiver) have sufficient training using the CGM prescribed as evidenced by providing a prescription 
   and
3. The CGM is prescribed in accordance with its Food and Drug Administration (FDA) indications for use 
   and
4. The beneficiary for whom a CGM is being prescribed to improve glycemic management meets at least one of the criteria below:
   A. Is insulin-treated
   or
   B. Has a history of problematic hypoglycemia (low blood glucose, also called low blood sugar) with documentation of at least one of the following:
   —Recurrent (more than one) level 2 hypoglycemic events (glucose <54mg/dL (3.0mmol/L)) that persist despite multiple 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. 
   and
5. Within six months prior to ordering the CGM, the treating practitioner has an in-person or Medicare-approved telehealth visit with you to evaluate your diabetes control and determine that criteria one through four above are being met.

1. Medicare now allows people to receive a CGM if they are treated with insulin—any type and any amount. (The CMS previously required people with diabetes to take a certain amount of insulin per day to access a CGM.) 
2. Medicare now allows individuals with diabetes who do not take insulin to receive a CGM if they have a history of problematic hypoglycemia. 
3. Within six months of ordering a CGM, a person must have an appointment with their provider. That appointment may now either be in person or via telehealth. 

This is effective as of April 16, 2023.

There are no requirements as to the type of insulin you take or how much, you just need to be prescribed insulin as a form of treatment for your diabetes. 

It does not matter what type of diabetes you have, just as long as you have a diabetes diagnosis and are taking insulin. 

No. The CMS will cover your CGM device as long as it is FDA-approved. 

You can find more information on this specific change on the CMS website and on this webpage.

We recommend you begin by speaking to your health care provider to see if using a CGM is a good option for you.