CGM coverage and medical policy

As continuous glucose monitoring (CGM) has become more integral to the modern standard of care for type 1 diabetes (t1d), CGM coverage has also evolved. Whether you're a healthcare provider prescribing CGM or a patient who relies on it, familiarizing yourself with medical policies that govern access to this technology can help to ensure continuity in this aspect of diabetes management.

CGM medical policies

In the United States, the Centers for Medicare and Medicaid Services (CMS) sets the baseline for health plans under Medicare, Medicaid, the health insurance marketplace, and the Children's Health Insurance Program (CHIP). It also sets the basic standard of care for private health insurance companies, so if you want to get insight into medical policy for CGM coverage, CMS guidelines are a great place to start.

For example, the CMS guidelines mention criteria for CGM coverage that includes a specific diabetes diagnosis code and insulin dependence requiring frequent adjustment based on blood glucose levels. A physician must oversee the prescription and use of the CGM materials after verifying patient eligibility.

Since private insurers look to CMS guidelines for their own policies, increased coverage of diabetes devices and medications by CMS tends to be positive for those on private insurance plans as well. These policies have evolved steadily as CGM has become a more commonly used tool in the clinical management of t1d. Since medical policy, whether governmental or private, can change at any time, it's important to research the newest developments when seeking device approval.

What to do if your CGM claim is denied

If you encounter a denial of CGM coverage, there are a few key items to keep in mind as you take your next steps.

Firstly, make sure you understand why the claim was denied. Sometimes denials stem from simple coding errors that result in automatic denial. One of the most common billing errors that can cause this to occur is if a patient's coding shows a type 2 diabetes diagnosis or there is an implication that the patient is not insulin dependent. If a coding error is present, the physician's office can fix the error and then restart the process over again. It should go more smoothly once the codes are corrected.

If the denial cause reaches beyond a coding error, taking a closer look at your insurance plan benefits can help you to find justification for an appeal. You can work with your doctor's office to put together an appeal for the insurance company. This process could range from starting with a simple form submission all the way up to a peer-to-peer review involving your doctor.

While an appeal takes place after the request for coverage has already been denied, requesting an exception to your plan is a step you can take prior to moving forward with the prescription. Explore the JDRF resource guide on this topic for support in applying for a plan exception as a means of receiving CGM coverage.

Increasing CGM coverage

As CGM continues to emerge as a standard of t1d care, more research is needed to help support coverage for folks living with other types of diabetes. At this time, people living with t1d or who rely on insulin to treat their diabetes are most well-positioned to receive coverage. Physician and patient advocacy alike can help to increase coverage, access, and affordability for this technology across the diabetes community as a whole.

Interested in finding out what kind of CGM might be the right fit for you? Check out this Edgepark Health Insights article to get an idea of what CGM technology options are available.