Preventing Denials for Therapeutic CGMs and Related Supplies

March 8th, 2018 - Medicare Learning Network
Categories:   Documentation Guidelines   DME|Supplies|Equipment   Denials & Denial Management  
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The Medicare Learning Network, provides coverage guidance on therapeutic CGMs and Related Supplies:

Medicare covers therapeutic CGMs and related supplies when you meet all of the following coverage criteria:

  1. The beneficiary has diabetes mellitus (Reference the ICD-10 Codes that Support Medical Necessity section for applicable diagnoses in LCD L33822)
  2. The beneficiary uses a BGM and performs frequent (four or more times a day) testing
  3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump
  4. The beneficiary’s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of their BGM or CGM testing results
  5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met
  6. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an inperson visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan
*If any of coverage criteria (1-6) are not met, the CGM and related supply allowance are denied as not reasonable and necessary. When Medicare covers a therapeutic CGM (code K0554), Medicare also covers the related supply allowance (code K0553).

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