Medicare and Diabetes Technology Insurance Coverage

//Medicare and Diabetes Technology Insurance Coverage
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I’m still a number of years  away from retirement and reaching Medicare age, but I have to admit that the current Medicare coverage (or lack thereof) for diabetes technology causes me to feel more than a little concern.  It’s awesome that people with diabetes are living normal lifespans, but the current Medicare system is not set up to provide coverage of the technologies that we become accustomed to using when we have commercial insurance coverage to control the disease as well as we can.

When you are young and have commercial health insurance, you use tools like brand name, accurate glucose meters, Continuous Glucose Monitors (CGMs), and insulin pumps.  Depending upon your insurance, you may have some restrictions on certain products, or pay more than you would like in co-pays.  But the technology or products you want are often not out of reach.  Many of the glucose meters on the market have programs which lower your co-pay for test strips.  You pay a co-pay and get your insulin.  You might prefer to use Novolog but your insurance pays for Humalog, but at least you can get your products.  You can probably get an insulin pump if you have Type 2 diabetes if you want one and your physician prescribes it.  And you can get a new insulin pump every four years when the old one goes out of warranty.  There can be a lot of variation in what is covered, and how much you pay out of pocket, depending upon your insurance coverage.  I realize that some people on commercial insurance have it a lot better than others.

Did you know that Medicare doesn’t cover insulin pumps the same way that commercial insurance does?  They require a test to prove that you don’t make your own insulin and need an insulin pump, as opposed to just wanting one to improve your diabetes management.  Type 1s can qualify, but it’s not the same for Type 2s.  What if you are a Type 2 who has been using an insulin pump for years?  It’s a huge step backwards to have your technology coverage taken away from you!  Medicare only pays for a pump once every 5 years for those who qualify, so people spend the last year using an out of warranty pump.  And there are limits on the choice of the pump with Medicare.

Blood glucose meters might be a little bit easier.  It’s not uncommon to hear from supply companies that various meters are not covered by Medicare.  But one of my meter reps recently assured me that Medicare pays for all brands of test strips.  The patient needs to go to a pharmacy that accepts assignment on Medicare.  Apparently all the chain pharmacies accept assignment, and many of the independents do as well.  If you have Medicare and the pharmacy says strips aren’t covered, it would be worthwhile to speak to your local meter rep (your endocrinologist’s office should be able to put you in touch with someone) and work with the pharmacist to determine how to secure test strip coverage for the meter of your choice.

Medicare does not cover CGMs.  Medicare’s coverage determination says that the CGM sensors, transmitter, and receiver are “convenience items” and are therefore not covered.   Moreover, CGMs aren’t covered because the Centers for Medicare and Medicaid Services says they don’t meet the Medicare definition of durable medical equipment and don’t fall under another Medicare category.  It doesn’t make sense that a tool which reduces risk and keeps people with diabetes out of the emergency room or hospital is deemed not worthy of insurance coverage.  Not fair that you could use CGM for years, turn 65, and have the rug pulled out from under you.

A short while back, a patient named Laura Siner from Maryland was able, with the testimony of her endocrinologist, Dr. Nick Argento, to secure Medicare coverage of her CGM after three separate appeals.   Dr. Argento articulated that Ms Siner was able to significantly improve her diabetes control only by using a Dexcom, and how detrimental this lack of control would be as she aged.  The American Diabetes Association, JDRF, and others have petitioned Medicare for CGM coverage, but thus far these efforts have not been successful.  Dr. Argento testified that CGM helps patients to reduce and control severe hypoglycemia, which is both dangerous and life-threatening.  He testified about two Medicare patients who died of severe hypoglycemia because they were unable to afford to pay out of pocket for CGMs.  Hypoglycemia isn’t a mere “inconvenience;” people die from it especially when unaware of symptoms.

Controlling diabetes can prevent complications of the disease.  It doesn’t take a genius to see that this would actually reduce medical costs in the future.  Type 1s should have coverage of CGM.  It’s very tough to get coverage on Medicare, but obviously, this proves that it’s not impossible.  Expect that you will be denied at the first levels of appeal, which are done on paper.  It’s not until the third level of appeal that you would have a hearing with an administrative law judge.  It helps if you were on CGM before going on Medicare, or if you are paying out of pocket for one while on Medicare.  Medicare won’t do pre-approvals, so you’ve got to have a CGM before you can ask for coverage.

Paying for CGM would cost Medicare less than paying for emergency room visits and hospital admissions that could have been avoided.  It’s ironic that the technologies that advance diabetes care and allow us to live long enough to attain Medicare age are not covered by Medicare!

The good news is that lots of people are working towards securing Medicare coverage of diabetes technology.  Petitions circulate, and diabetes organizations support having technologies covered by Medicare.  Bills in congress seek to require Medicare to cover CGM.  I really hope that we can get there.

The task of diabetes advocacy belongs to all of us.  One easy way that you can get your elected officials to hear you is to go through the Diabetes Patient Advocacy Coalition web site.    Another option is to contact JDRF and become an advocate.  We need to make our voices heard.

By | 2016-10-14T19:10:39+00:00 October 14th, 2016|Thinking Like A Pancreas Blog|1 Comment

About the Author:

Integrated Diabetes Services is the worldwide leader in one-on-one consulting for people who use insulin. Diabetes “coaching” services are available in-person and remotely via phone and the internet for children and adults.

One Comment

  1. Tricia Finigan November 16, 2016 at 6:42 pm - Reply

    Dear Lisa,
    Thank you for this CGM Medicarecoverage update. I have been going through the appeal gauntlet for three years plus. I won my ALJ
    & it was reversed on appeal.
    I filed a case against Secretary of Health and Human Services in Federal court. Case was found in my favor and now has been sent back to same ALJ who originally found in my favor. The hearing is by phone at 1:00 pm tomorrow.11/17/16. I have won on the medical necessity but now they are challenging DME.
    Is there any way To get information on case number or where to locate actual ruling in the case that was won?
    I would like to refer to it in my testimony? It would be very impressive if I could refer to actual case in legal terminology. I’m
    Sure the lawyer for Medicare is aware but doubtful they’d acknowledge
    that during the hearing.
    Lastly, I want to increase awareness regarding a subgroup of T1D who have been placed in the Medicare pool due to disability . I had been using pump and CGM while employed and had access to commercial
    Insurance . Once I became disabled due to complications from my nearly 50 years of T1D I lost CGM coverage,15 or more years away from retirement age and Medicare! There are a lot of us under 65 years of age afected by Medicare policy on this issue.
    Thank you for your advocacy , please contact me if you can add any information with regard to my hearing(very short notice)
    Tricia Finigan

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