Have you been denied Medicare coverage for CGM?

By Lisa Foster-McNulty, MSN, RN, CDE

If you are a low-income Medicare beneficiary with diabetes who requires multiple daily injections of insulin, or insulin pump therapy, and also have hypoglycemia unawareness, we have some good news for you! 

You may be eligible to receive help with your appeal if you have been denied coverage by Medicare for a continuous glucose monitoring (CGM) system. Taking Control of Your Diabetes (TCOYD) has received a grant from the Leona B. and Harry M. Helmsley Charitable Trust to enable them to assist eligible seniors with the CGM appeals process.

In order to be considered for this program, an applicant has to meet certain criteria.

1. Your diabetes requires multiple daily injections or use of an insulin pump, and you have hypoglycemia unawareness.  This means you don’t recognize when your blood glucose levels are too low. 
2. Before you went on Medicare, you had private health insurance coverage for your CGM.
3. Medicare has denied you coverage of CGM.  You have filed a request for redetermination (this is the first level of appeal) and you were denied again.
4. You can provide a copy of the redetermination decision letter from Medicare denying the first level of appeal.
5. You have a physician who is willing to sign a statement of medical necessity.
6. You have medical records that can be submitted to support the Medicare appeal if this is requested.
7. Applicants must agree to have their favorable Administrative Law Judge decision shared and added to the administrative record on appeals.  The reason for this is to send a message to Medicare that this is an important issue affecting many people.
8. Your gross annual pre-tax household income is below the median income in your state for a household of the same size.

Additional details, including the application for download, are found at https://tcoyd.org/resources/cgm.html?utm_source=streamsend&utm_medium=email&utm_content=27369133&utm_campaign=August%20E-Updates%20from%20TCOYD

Applications are evaluated on a first come, first served basis.  All applications received will be acknowledged, and applicants who are eligible for assistance will be notified by phone.