Who Qualifies for a CGM? Medicare Basics & Outcome Talking Points for Diabetes Care
As continuous glucose monitors (CGMs) become a cornerstone of modern diabetes management, providers need clarity on CGM coverage criteria, documentation requirements, and how to effectively communicate the value of CGMs to patients.
In April 2023, the Centers for Medicare & Medicaid Services (CMS) expanded CGM coverage to align with American Diabetes Association (ADA) standards, making it easier for more individuals with diabetes to qualify.
At NextGen Medical Supplies, we help endocrinologists, primary care providers, and diabetes educators simplify this process through insurance support, compliance review, and patient onboarding.
Medicare CGM Coverage: 2023 Expansion Overview
CMS broadened eligibility for CGMs under the Medicare Part B DME benefit (effective April 16, 2023). The updated policy expanded coverage to include patients using any insulin regimen or those with problematic hypoglycemia, even if not using insulin.
Who Qualifies:
Patients must meet one of the following criteria:
- Have a diagnosis of diabetes mellitus, and
- Be treated with any insulin regimen (basal, bolus, or pump therapy)
OR
- Be treated with any insulin regimen (basal, bolus, or pump therapy)
- Have a history of problematic hypoglycemia, including:
- Recurrent Level 2 events (<54 mg/dL) despite treatment adjustments, or
Additional Requirements
- The CGM must be prescribed per FDA indications.
- The patient or caregiver must receive training on proper CGM use.
- A face-to-face or telehealth visit must occur within 6 months of the original order.
CGM Documentation Checklist for Coverage
Comprehensive documentation ensures a smooth approval process. Include the following in the medical record and Standard Written Order (SWO):
Medical Record Must Show:
- Diagnosis of diabetes mellitus (ICD-10 codes such as E10–E11 series)
- Insulin use or documented hypoglycemia history
- CGM prescribed per FDA guidelines
- Evidence that the patient or caregiver received training
- Visit note within 6 months of the CGM order
Standard Written Order (SWO) Must Include:
- Patient name
- Item description (e.g., “continuous glucose monitor”)
- Quantity and frequency of supplies
- Treating practitioner’s name, NPI, and signature
Continued Coverage:
To maintain coverage, patients must have a follow-up visit every 6 months documenting continued CGM use and medical necessity.
Quick Talking Points for Patient Conversations
When introducing CGMs to patients, concise, outcome-based messaging helps build understanding and trust.
Improved Outcomes
- Lower A1C without additional medications
- Increased Time-in-Range (TIR), which is associated with fewer complications
- Fewer hypoglycemia events, particularly overnight
Lifestyle Benefits
- Real-time alerts for highs and lows
- Personalized insights into how meals, stress, and activity affect glucose
- Less reliance on fingersticks
Peace of Mind
- Data sharing with caregivers or family
- Predictive alerts for urgent lows
- Greater confidence during travel, holidays, and daily routines
Partner with NextGen Medical Supplies
NextGen Medical Supplies partners with clinicians to make CGM prescribing and fulfillment simple, compliant, and patient-friendly. Our team supports every step of the process by:
- Reviewing documentation for Medicare and insurance compliance
- Coordinating insurance verification and prior authorization
- Assisting with patient onboarding, training, and follow-up
Need help with a referral or coverage check? Contact NextGen Medical Supplies to get started today.
