Appeal type: unknown
Decision: unknown

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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say continuous glucose monitoring (CGM) devices covered by Medicare under the DME benefit are 
defined in CMS Ruling 1682R as therapeutic CGMs. Refer to the Non-Medical Necessity Coverage and 
Payment Rules in the LCD-related Policy Article for additional information. 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, A52464, for applicable diagnoses); and, 
 
2.   The beneficiary has been using a blood glucose monitor (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 information in Local Coverage Determination, Glucose Monitors, L33822. 
 
If the information in the patient's medical record does not adequately support the medical necessity for the 
item, the supplier is liable for the dollar amount involved unless a properly executed Advance Beneficiary 
Notice (ABN) of possible denial has been obtained. You can find this rule in the Medicare Program Integrity 
Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10. 
 
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.