Debra Parrish is an attorney who has been working with T1 appeals on Medicare denials of CGM coverage. Her email about Medicare coverage with the first one I received in January. But today, she put out a caution that there still may be obstacles.
Parrish Law Offices: Durable Medical Equipment Update – CMG
March 2017 Issue
Medicare’s Coverage of CGM Still Raises Issues
In January 2017, CMS issued Ruling 1682-R indicating that continuous glucose monitors (“CGM”) that are FDA-approved to replace finger sticks, “therapeutic CGM,” are eligible for Medicare coverage. Although the Medicare contractors have not revised the article that states Medicare considers all CGM to be “precautionary,” on March 23, 2017, the Medicare contractors issued another article stating “therapeutic CGM” will be covered. The Medicare contractors have indicated that they will revise the existing local coverage determination and policy article and make them retroactive until January 12, 2017, the date CMS issued Ruling 1682-R which found that the Dexcom G5 satisfied the statutory definition of durable medical equipment and thus could be covered by Medicare. The new article indicates that other than the Dexcom G5, Medicare will not cover CGM.
Articles are supposed to convey only coding and billing information, but the new article also lays out coverage criteria for the Dexcom G5: (1) the beneficiary has diabetes; (2) the beneficiary has been using finger stick testing at least four times a day; (3) the beneficiary is insulin-treated; and (4) the beneficiary’s insulin treatment requires frequent adjustment.
Unfortunately, the article indicates more hurdles for Medicare beneficiaries.
First, all the claims associated with a “therapeutic CGM,” i.e., Dexcom G5, must billed using miscellaneous codes – E1399 and A9999. Typically items billed under a miscellaneous code initially are denied by Medicare and […]