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 must be appealed to receive coverage and payment.
- Second, the new article indicates that if Medicare beneficiaries use their Dexcom G5 with a smart phone, even if such use is in addition to using the receiver that comes with the Dexcom G5 system, all the CGM supplies will be non-covered. This restriction is nonsensical – durable medical equipment does not become non-durable if a Medicare beneficiary uses a smart phone app with the device. This novel restriction appears to be designed to ensure that the only CGM that is covered by Medicare will not be covered for those individuals who use it to its full functionality to monitor their glucose levels.
- Third, Medicare beneficiaries using a Dexcom G5 will no longer be able to submit claims for extra test strips for their finger stick monitor – such claims will be denied.
Thus, it appears Medicare beneficiaries will continue to face obstacles in securing Medicare coverage for CGMs and related supplies. |
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Well, this is the second shoe to drop. But being the second shoe, it is the 3rd shoe that scares me. That shoe is when private health plans adopt the medicare model. That will be coming quickly.
This article makes me a little sick. It appears that the criteria is designed to exclude coverage, not guarantee that it is available for everyone who needs it. In particular, the limitation of test strips is ridiculous, and restricting the use of a smartphone is absolutely nuts for those intent on controlling blood sugars.
How does this happen and who writes these regulations? I smell lobbyist money going into multiple pockets.
Why does it have to be so hard to get the equipment needed to manage diabetes and save lives? This is health care out of control.