CGM and Medicare

Dr. Bill Quick Health Pro
  • CGM (continuous glucose monitoring) has become a well-accepted, although expensive, component of diabetes care. It's particularly helpful for people on insulin, who risk hypoglycemia or hyperglycemia if there's a mismatch between their insulin dose and food or activity levels. Commercially-available CGM devices consist of an embedded sensor that measures subcutaneous glucose levels (scGLs) (which correlate nicely with blood glucose levels (BGLs)), and a transmitter that sends the scG information wirelessly to a third component, a receiver that displays the information. And one brand of CGM integrates the CGM receiver with an insulin pump.

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    CGM devices indicate trends of what's been occurring with the BGLs over the very recent past, and can sound the alarm when scGLs are high or low or rapidly-rising or rapidly-falling. Thus, as an example, when a patient is asleep and their BGL and scGL crashes into the hypoglycemic range, an alarm can awaken them (or their bed-partner) rather than risk prolonged hypoglycemia. Simply avoiding one expensive emergency room visit for a severe hypo could offset the considerable cost of the device and supplies.


    CGM provides information about the direction that BGLs are going; early notification of oncoming lows and highs; alerts for lows or highs anytime (especially important while sleeping or driving), and insights into how food, physical activity, medication, and illness affect diabetes.


    Plus there are now numerous reports showing that CGM can help long-term diabetes control. For instance, a study from several years back showed that CGM-augmented pump therapy resulted in significant improvement in A1C levels compared to multiple daily insulin injections. And CGM is proven to be helpful in people with type 2 diabetes: a one-year study showed that real-time CGM is significantly better at controlling blood glucose in people with type 2 diabetes than the more traditional method of self-monitoring of blood sugar (SMBG) at meal times and bedtime.


    Most private insurance companies accept CGM as a component of diabetes care that will be covered financially, assuming the physician documents that the device is medically necessary. (Google "medically necessary CGM" to see various companies' requirements for CGM coverage.)


    BTW, I'd expect that most people with CGM devices are using them differently from the recommendations of the companies and of the ADA, who state "These sensors require calibration with SMBG, and the latter are still required for making acute treatment decisions." As a CGM user myself, I've learned to trust the scGL trends to help decide that I need more insulin if the scG trend is upward, or food if I've crashed into hypoglycemic values -- without dropping everything to search for whereever I left my meter and doing a BGL to verify what the CGM device says.


    But Medicare (and the VA) refuse to provide coverage for this very expensive gadget. It appears that they would rather cut costs in the short-term, even if the device could prevent higher emergency room and hospital expenses, long-term complication costs, and overall lower health care costs down the line. And for folks who have had their CGM covered by private insurance, it's galling (to say the least!) to find that CGM coverage ceases when Medicare takes over their health-care coverage.


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    There's lots of discussion amongst diabetes bloggers about this sad situation, and horror stories of appeals for coverage that eventually go down the drain of ineffective administrative bureaucracy. I attended a webinar yesterday where a group of fellow senior citizens gave more sad stories.


    Getting Federal laws changed should help, but realistically, that's not going to happen. I just looked at a website that described the chances for a recent bill, H.R. 3710: Medicare CGM Coverage Act, as having a prognosis of "0% chance of being enacted."


    Of course, you can sign a petition. There are several on-line you could choose from to sign (or I guess you could sign them all!). The biggest petition seems to be from JDRF; as of today, there are 49,325 folks who've signed it.


    But getting politicians and bureaucrats to take notice in this era of Federal do-nothing government is whistling down the wind. Sometimes it seems that the only viable solution would be to win the lottery. Or maybe have some hypothetical politician with T1D start using CGM, and having that pol push to have legislation passed.


    Oh well, I can hope.

Published On: August 27, 2014