The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have announced a policy change expanding coverage for continuous glucose monitors (CGMs). The decision, which the Centers for Medicare & Medicaid Services (CMS) hopes will decrease health disparities in the diabetes community, is expected to improve health outcomes for many Medicare beneficiaries with diabetes, while reducing Medicare spending for the treatment of diabetes-related complications.
When Applied Policy first reported on the proposed expansion in November, it was expected to extend coverage to persons using insulin at least once a day (compared to the existing threshold of three times daily) or to those with a history of problematic hypoglycemia. However, as adopted, the policy does not include language specifying a minimum daily dosing frequency, but uses the term, “The beneficiary is insulin-treated.” As a result, the coverage expansion is larger than had been anticipated.
The policy defines two pathways to coverage for beneficiaries with diabetes and a history of problematic hypoglycemia.
Medicare beneficiaries with CGMs will still be required to meet with their treating practitioner in person or by telehealth every six months to assess adherence with their CGM regimen and treatment plan.
The DME MACs’ decision comes after diabetes stakeholders, including the Diabetes Technology Access Coalition, endocrinologists, and Applied Policy employed the latest diabetes research and clinical evidence and practice to quantify the value of an expansion of CGM coverage for Medicare beneficiaries. By measuring interstitial glucose levels on an ongoing basis and transmitting measurements to an external monitor or smart device at regular intervals, CGMs allow for more precise of management of glucose levels.
For Medicare beneficiaries, the changes to CGM coverage policies are extremely timely. Under the Covid-19 Public Health Emergency Waivers, CMS waived enforcement of clinical indications for CGMs. As a result, many beneficiaries who did not qualify for a CGM under the current coverage policies have been put on CGMs in the last three years. The expansion of CGM coverage policy, which goes into effect before the end of the public health emergency on May 11th, will allow at least some of these beneficiaries to now qualify under the new criteria and prevent beneficiaries from being taken off therapy.
Applied Policy is proud to have contributed to this change through development and submission of a policy recommendation which outlined a pathway to promote health equity in diabetes care and management that can reduce federal spending for diabetes-related complications.
The new policy is effective April 16.