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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 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 LCDrelated
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 Medicarecovered
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 inperson
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.
To be eligible for coverage of home blood glucose monitors and related accessories and supplies, the
beneficiary must meet both of the following basic criteria (1) - (2):
1. The beneficiary has diabetes (Reference ICD-10 Codes that Support Medical Necessity section for
applicable diagnoses); and
2. The beneficiary's physician has concluded that the beneficiary (or the beneficiary's caregiver) has sufficient
training using the particular device prescribed as evidenced by providing a prescription for the appropriate
supplies and frequency of blood glucose testing.
Code E2101 is also covered for those with impairment of manual dexterity when the basic coverage criteria
(1)-(2) are met and the treating physician certifies that the beneficiary has an impairment of manual dexterity
severe enough to require the use of this special monitoring system. Coverage of code E2101 for beneficiaries
with manual dexterity impairments is not dependent upon a visual impairment.
You can find this information in Local Coverage Determination (LCD): Glucose Monitors (L33822).
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.