Coverage of Insulin Pump and the CGM

[RobertG801520]

Yes, I am trying to get a Medtronic Insulin Pump and the CMG that goes with it. I have been going back and forth with my Medicare Advantage Plan Company and the ones that are contracted to handle both plus the supplies that go with it. I have been going back and forth for the last two weeks. Finally, they approved the Insulin Pum and supplies but they say the CGM is not covered. After doing extensive research I have found out that Medicare and Advantage Plans are required since 2023. To give both including supplies and I has the patient will be required to pay 20%. What do I need to do? Contact Medicare directly or who do I need to speak with about this? Thanks

[SteveW876191]

If you are on Medicare and have a supplemental Part B insurance, everything should be covered between the two. It takes your doctor to submit the request for a pump and CGM. Once that is received by Medtronic's, they will submit the request to Medicare for approval. This may take a couple of weeks. Once the system is approved, you will receive notification from Medtronic's that it has been approved and should receive the Pump, the reservoir that goes into the pump, the set that is inserted for insulin delivery, CGM, and manuals from Medtronic's along with direct training on the ussage of the system from a local representative by direct contact and personal visit to get you started.

Every year, the doctor's office will have to submit a report that Medtronic's will provide and submit to Medicare after completion to complete the order and also approves the continued approval to receive the sets and reservoirs. You will also have to have the Dr. submit a request to your pharmacy for the insulin. Be sure and have them stipulate that the insulin amount is enough to cover your usage per month, request a 3-month supply of insulin and assure that your pharmacy understands that insulin used with an insulin pump is a durable goods so it is also covered 100% by Medicare.

The reservoir and set will need to be ordered from another supplier as I could not get the supplies through the pharmacy. Medtronic's will provide you with the name of a supplier and this supplier may also request approvals from Medicare and from you DR. in order to supply the items. II suggest that you set up your supplies with automatic refill to reduce the possibility of running out of any supplies.  Be aware that using more insulin than the Dr prescribes can cause you to run low or out at the end of prescription and then it gets really difficult to have more insulin provided for free through Medicare. It is rare but you can also have a set not function properly or it fails during the insertion process. If this happens, notify Medtronic's technical department and they will ask a lot of questions, but will send out a replacement set at no cost to you. 

I suggest getting the G780 pump which requires a different set than other models of pump or CGM only for your body. This pump automatically adjusts your insulin usage based on your CGM readings every 5 minutes to compensate for poor eating or exercise causing highs or low glucose.  The best thing is that this unit does not require fingerstick for calibration unless it detects some strange reading and will ask for you to perform a fingerstick test for recalibration. This unit also connects to the internet and allows you to monitor your system through your phone. All actual insulin control has to be completed through the pump. 

Hopefully this will help. Medtronic's has been an excellent company to work with and are always very helpful, not matter what my problem.

[GailL1]

Medicare - whether under Original Medicare or under managed care like a Medicare Advantage plan - will cover CGM under DME (durable medical equipment) as long as it is medically necessary.  They determine this medical necessity by documented measures obtained from your doctor.

If your doctor determines that you meet all the coverage requirements, Medicare covers continuous glucose monitors and related supplies for making diabetes treatment decisions (like changes in diet and insulin dosage).

The requirements include the need to:

• Frequently check your blood sugar (4 or more times a day), and
• Either use an insulin pump or get 3 or more insulin injections per day.

You must also make routine in-person visits with your doctor.

This isn’t a complete list - your doctor should know,  It has to be therapeutic and not just for some  convenience.  

So just make sure that your doctor is documenting your current monitoring procedure and why this isn’t working as well as a CGM regiment and you have those regular checks with the doc - in person or within telemedicine.

Medicare.gov - Therapeutic Continuous Glucose Monitoring Coverage