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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare pays for therapeutic continuous glucose monitors (CGMs) when they are medically 
reasonable and necessary. Therapeutic CGMs are defined in CMS Ruling 1682R. You can find these rules in 
Local Coverage Article A52464, effective on and after January 12, 2017. 
 
CGMs consist of three components: a glucose sensor, a transmitter, and a receiver. CGMs are considered 
therapeutic CGMs if they are: 
  approved by the FDA for use in place of a blood glucose monitor for making diabetes treatment decisions (for 
  example, changes in diet and insulin dosage); 
  generally not useful to the individual in the absence of an illness or injury; 
  appropriate for use in the home; and 
  those which include a durable component that can withstand repeated use, are expected to last at least three 
years, and are capable of displaying the trending of the continuous glucose measurements. 
 
The rules also say that a CGM which does not replace a blood glucose monitor for making diabetes treatment 
decisions is not covered. You can find these rules in CMS Ruling 1682R. 
 
The rules say therapeutic CGMs and related supplies are covered by Medicare when all of the following 
coverage criteria (1-6) are met: 
1. The beneficiary has diabetes mellitus (Refer to the "ICD-10 Codes that are Covered" section of the LCD 
related Policy Article for applicable diagnoses); and, 
2. The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and, 
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; and, 
4. The beneficiary?s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of 
BGM or CGM testing results; and, 
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; and, 
6. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person 
visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. When a 
therapeutic CGM (code K0554) is covered, the related supply allowance (code K0553) is also covered. 
 
If any of coverage criteria (1-6) are not met, the CGM and related supply allowance will be denied as not 
reasonable and necessary. You can find this rule in the Local Coverage Determination (LCD): Glucose 
Monitors (L33822) effective January 1, 2019. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Medicare 
Program Integrity Manual Chapter 3 Section 3.3.2.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.