CMS issues coverage criteria, billing codes for therapeutic CGMs

By Jonah Comstock
03:59 pm

In January, the Centers for Medicare and Medicaid Services announced that it would cover continuous glucose monitoring for the first time; specifically it would cover therapeutic CGMs, of which the only one currently recognized is the Dexcom G5. That coverage officially kicks in today, now that CMS has issued the billing codes providers can use to get reimbursed.

“This is a new era and a huge win for people with diabetes on Medicare who can benefit from therapeutic CGM,” Dexcom president and CEO Kevin Sayer said in a statement. “This decision supports the emerging consensus that CGM is the standard of care for any patient on intensive insulin therapy, regardless of age.”

A CGM is therapeutic when its data can be reliably used for treatment decisions, as determined by the FDA. While Dexcom's is currently the only device that meets this standard, others are pursuing it (for instance, Senseonics CEO Tim Goodnow said on a recent earnings call that the clearance was 'high on out to-do list').

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The new codes have four requirements for reimbursement: that the patient has diabetes, that they have been using a home glucose monitor and checking their glucose frequently, that they take insulin either multiple times per day or continuously via a pump, and that their insulin requires frequent adjusting.

Essentially, CMS will cover a CGM if the data it's providing is essential to the patient's day-to-day treatment. Additionally, consumer smartphones or tablets that are used to run the Dexcom app are explicitly not covered.