Insurance Coverage for CGM systems varies from plan to plan, and it is improving all the time.

Although Medicare does not currently pay for CGM, several major private plans offer some level of coverage.  These include:

  • Blue Cross/Blue Shield
  • Aetna
  • Cigna
  • Humana
  • United Healthcare
  • Kaiser Permanente
  • Wellpoint

CGM is usually considered “durable medical equipment” and is subject to the same deductibles and copays as other types of DME.  Every CGM company has a team of specialists dedicated to helping you obtain maximum coverage.  Do your best to comply with their requests and supply them with the information they need to support your case.

People with Type-1 (insulin-dependent) diabetes often qualify for insurance coverage, particularly if the following criteria are met:

  • A history of hypoglycemia, documented in the physician’s chart/records
  • Presence of hypoglycemia unawareness (lack of symptoms during the early phases of hypoglycemia)
  • Erratic blood glucose levels
  • Suboptimal HbA1c
  • Frequent blood glucose monitoring
  • Having completed diabetes self-management education

In some cases, people with Type-2 diabetes, whether or not insulin is used, can obtain coverage if many of these same conditions exist.

Most plans require the CGM to be prescribed by an endocrinologist.  Letters from both you and your physician, supporting your need for CGM, are often helpful.  And persistence pays!  If you are denied for coverage the first time around, go through the appeal process.  Many people who were initially denied are approved for coverage after the second, third, and even fourth round of appeals.

Whenever possible, request an “external” appeal.  This requires your health insurer to pay a physician who is not employed by their company to review your case in detail.  An external appeal will usually cause the health insurance company to overturn their decision and begin covering your CGM.

Resources for Obtaining Coverage

The Juvenile Diabetes Research Foundation details the Steps for obtaining case-by-case coverage for CGM at its website:
http://jdrf.org/

CGM Coverage Policies for Select Health Plans are listed at:
http://jdrf.org/t1d-resources/

 

Excellent sample letters for establishing medical need can be found at:

http://www.diabeteshealth.com/read/2009/02/27/6096/sample-request-for-cgm-insurance-coverage/

 

For Additional resources for CGM Insurance Coverage, visit the CGM Anti-Denial Campaign Website:

http://cgm-antidenial.ning.com

Research To Support Your Case

Bailey TS, Zisser HC, Garg SK. Reduction in hemoglobin A1C with real-time continuous glucose monitoring: results from a 12-week observational study. Diabetes Technol. Ther. 2007. 9: 203-10.

Boland E, et al.  Limitations of conventional methods of self-monitoring of blood glucose: lessons learned from 3 days of continuous glucose sensing in pediatric patients with type 1 diabetes. Diabetes Care 2001;24:1858-1862. 

Cemeroglu AP, et al. Use of a real-time continuous glucose monitoring system in children and young adults on insulin pump therapy: patients’ and caregivers’ perception of benefit. Pediatr Diabetes. 2009 Dec 2.

[Epub ahead of print]

Danne T, et al.  Reducing glycaemic variability in type 1 diabetes self-management with a continuous glucose monitoring system based on wired enzyme technology.  Diabetologia. 2009 Aug; 52(8):1496-503. Epub 2009 Jun 13.

Deiss D, Bolinder J, Riveline J-P, et al. Improved glycemic control in poorly controlled patients with type 1 diabetes using real-time continuous glucose monitoring. Diabetes Care 2006; 29:2730-2732. 

Diabetes Research in Children Network (DirecNet) Study Group. Continuous glucose monitoring in children with type 1 diabetes. J Pediatr 2007; 151:388-393. 

Garg S, Zisser H, Schwartz S, et al. Improvement in glycemic excursions with a transcutaneous, real-time continuous glucose sensor: a randomized controlled trial. Diabetes Care 2006; 29:44-50. 

Deiss D, Bolinder J, Riveline JP, Battelino T, Bosi E, Tubiana-Rufi N, Kerr D, Phillip M. Improved glycemic control in poorly controlled patients with type 1 diabetes using real-time continuous glucose monitoring. Diabetes Care 2006, 29: 2730-2.

Freeman, et al. The use of continuous glucose monitoring to evaluate the glycemic response to food. Diabetes Spectrum. 2008;21(2):134-137.

Garg S, Jovanovic L. Relationship of fasting and hourly blood glucose levels to HbA1c values: safety, accuracy, and improvements in glucose profiles obtained using a 7-day continuous glucose sensor. Diabetes Care. 2006; 29: 2644-

Garg SK, et al. Continuous home monitoring of glucose: improved glycemic control with real-life use of continuous glucose sensors in adult subjects with type 1 diabetes. Diabetes Care. 2007;30(12):3023-3025.

JDRF CGM Study Group. JDRF randomized clinical trial to assess the efficacy of real-time continuous glucose monitoring in the management of type 1 diabetes: research design and methods. Diabetes Technol Ther 2008; 10:310-321. 

The Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group.  Continuous glucose monitoring and intensive treatment of type 1 diabetes. N Engl J Med 2008; 359.

Kaufman FR, Austin J, Neinstein A, et al. Nocturnal hypoglycemia detected with the Continuous Glucose Monitoring System in pediatric patients with type 1 diabetes. J Pediatr 2002;141:625-630.

Klonoff DC. Continuous glucose monitoring: roadmap for 21st century diabetes therapy. Diabetes Care 2005; 28:1231-1239.

Kovatchev B, Anderson S, Heinemann L, Clarke W. Comparison of the numerical and clinical accuracy of four continuous glucose monitors. Diabetes Care 2008; 31:1160-1164. 

Roy W. Beck, M.D., PhD (jdrfapp@jaeb.org) and Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group.  Effectiveness of Continuous Glucose Monitoring in a Clinical Care Environment: Evidence from the JDRF-CGM Trial.  Diabetes Care ; published ahead of print October 16, 2009.

Ryan EA, Germsheid J.  Use of continuous glucose monitoring system in the management of severe hypoglycemia.Diabetes Technol Ther.  2009 Oct; 11(10):635-9.

Zisser H, et al. Accuracy of a Seven-Day Continuous Glucose Sensor Compared to YSI Blood Glucose Values. 27th Workshop of the AIDPIT Study Group, 2nd European Diabetes Technology and Transplantation Meeting (EUDDT): Poster S 03. Jan 2008.