Coming sooner than expected, Medicare recently clarified coverage criteria for the Dexcom G5, paving the way for Medicare to reimburse for people with both Type 1 and Type 2 Diabetes requiring intensive insulin dosing to use the Dexcom G5 mobile.

Dexcom and the diabetes community heralded the exciting news, as the lack of CGM coverage for Medicare patients had previously been a glaring oversight. Dr. Steven Edelman, founder of TCOYD, often joked about this, saying, “Good news! According to Medicare, Type 1 diabetes is cured when you turn 65!”

Despite the good feelings all around, a closer look at the Medicare document includes some concerning language that might forbid users to take advantage of one of the most useful features of the Dexcom G5: the ability to view sugars on your smartphone or smartwatch.

First, the good news: Medicare reimbursement for both Type 1 and Type 2 Diabetes on Dexcom G5

Dexcom proudly touted the fact that U.S. Centers for Medicare & Medicaid Services (CMS) issued guidelines that allowed for Dexcom G5 reimbursement for patients with either Type 1 or Type 2 diabetes who intensively manage their insulin. More specifically, they listed the following criteria that must all be met:

  • The beneficiary has diabetes mellitus; and,
  • The beneficiary has been using a home blood glucose monitor (BGM) and performing frequent (four or more times a day) BGM testing; and,
  • The beneficiary is insulin-treated with multiple daily injections (MDI) of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and,
  • The patient’s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of therapeutic CGM testing results.

Keep in mind these guidelines currently only apply to the Dexcom G5 Mobile system, as it is currently the only Continuous Glucose Monitor (CGM) to be FDA approved for “non-adjunctive use”, meaning it can be used for treatment decisions without a confirmatory fingerstick glucose measurement. (Calibrations with fingersticks are still required).

The bad news: no smartphone usage?

I’m admittedly not an expert when it comes to medical billing, but reading the CMS document more closely reveals some concerning information. In a section titled “Miscellaneous”, it states:

Coverage of the CGM system supply allowance is limited to those therapeutic CGM systems where the beneficiary ONLY uses a receiver classified as DME to display glucose data.  If a beneficiary uses a non-DME device (smart phone, tablet, etc.) as the display device, either separately or in combination with a receiver classified as DME, the supply allowance is non-covered by Medicare

By my interpretation of that phrase, it appears that Medicare would not cover users who use an iPhone or Apple Watch to view their blood sugars. I can understand why not using the dedicated Dexcom receiver might be discouraged by CMS since it’s solely built for medical use (unlike a smartphone, which can be less reliable), but the wording clearly also bans the use of a smartphone in combination with a receiver. That’s ridiculous.

Your initial reaction might be that many elderly patients (most of the patients on Medicare are above the age of 65) are not tech-savvy enough to use their smartphone, but my experience has shown that a surprising amount of older patients are quite adept at using the latest tools.

Now, the bigger question is this: can Medicare actually enforce this stipulation? Any patient receiving the Dexcom G5 System receives a separate receiver anyway, and how can Medicare police who is using the smartphone as the display device. Keep in mind, taking advantage of the Dexcom Share Cloud platform and Dexcom Clarity clinical tools require the app to be installed on a nearby smartphone, which may or may not fit the definition of using a “non-DME device as the display device.”

Reassuringly, Dexcom doesn’t seem to be too concerned about this caveat, as their press release did not include any mention of this. We’ll continue to follow this as the real-world application of these guidelines unfold…

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    I just changed over to the Dexcom G5 per my Dr’s direction for many reasons. The most important being the Dexcom APP which allows me to share my blood-glucose levels that are too low with loved ones. This is especially helpful to me being a life-long Type 1 now suffering from Unaware Hypoglycemia.
    I am however, confused and outraged that Medicare has blocked this added safety option of utilizing the APP in addition to the Dexcom receiver for ALL Medicare patients. They have gone as far as to make Dexcom create a different G5 meter (different packaging, software, and labeled Medicare) that blocks this APP feature. And they have threatened ALL patients that if found using the APP that any Medicare coverage will cease and ALL past coverage fees will be owed by patients!
    This is outrageous! Why are they blocking this potentially live-saving additional resource from Diabetics? How the hell can they get away this?
    All Diabetics must unite to demand that Medicare is forced to undue this absurd denial that can only hinder Diabetes Management. Together, our. Collective voice cannot be ignored!!
    I urge us all to contact our local elected officials to pressure Medicare to allow ALL Dibetics the ability to use the Dexcom APP in addition to the Dexcom receiver to better manage their blood sugars with this Chronic, Progressive, and Dibilitating Ilness!

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    The DEXCOM requires the Physician to send them charts of the patients every often, and if they do not get charts the Patient do not get supply. How often do DEXCOM needs to receive these charts? Is it Medicare requirements?

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    It’s official! If you’re on Medicare and use a CGM, you can now use your smartphone with it. A very informative article with all the details can be found here:

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    I just received a letter from Medicare the states, in summary, that, effective June 7, 2018, the Centers for Medicare and Medicaid Services revised their guidance for the use of alternate CGM display units, making them eligible for the CGM supply allowance payment when used in combination with the Dexcom CGM unit. Therefore, when the Dexcom receiver is used sometimes and the t:slim pump is used at other times, coverage of the monthly CGM supply allowance is now allowed.
    I am now using my t:slim pump during the day and my Dexcom receiver overnight. I always use my iPhone with both (and my husband is my follower). Just remember that a single transmitter cannot be connected to both the pump and Dexcom receiver at the same time.

  5. Does anyone know why edgepark has contracted with dexcom and does not honor Medicare coverage for g5 sensors. Where can I get g5 sensors and transmitters using Medicare coverage? Thank you

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