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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 CFR 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 than infusion pump is covered for administration of continuous subcutaneous insulin for the treatment of diabetes mellitus if criterion A or B is met, and if criterion C or D is met: A. C-peptide testing requirement - must meet criterion 1 or 2 and criterion 3: 1. C-peptide level is less than or equal to 110 percent of the lower limit of normal of the laboratory's measurement method. 2. For beneficiaries with renal insufficiency and a creatinine clearance (actual or calculated from age, weight, and serum creatinine) less than or equal to 50 ml/minute, a fasting C-peptide level is less than or equal to 200 per cent of the lower limit of normal of the laboratory's measurement method. 3. A fasting blood sugar obtained at the same time as the C-peptide level is less than or equal to 225 mg/dl. B. Beta cell autoantibody test is positive. C. The beneficiary has completed a comprehensive diabetes education program, has been on a program of multiple daily injections of insulin (i.e., at least 3 injections per day) with frequent self-adjustments of insulin dose for at least 6 months prior to initiation of the insulin pump, and has documented frequency of glucose self-testing an average of at least 4 times per day during the 2 months prior to initiation of the insulin pump, and meets one or more of the following criteria (1 - 5) while on the multiple injection regimen: 1. Glycosylated hemoglobin level (HbA1C) greater than 7 percent 2. History of recurring hypoglycemia 3. Wide fluctuations in blood glucose before mealtime 4. Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL 5. History of severe glycemic excursions D. The beneficiary has been on an external insulin infusion pump prior to enrollment in Medicare and has documented frequency of glucose self-testing an average of at least 4 times per day during the month prior to Medicare enrollment. You can find this rule in Local Coverage Determination (LCD): External Infusion Pumps (L33794) - Effective January 1, 2020. The rules say that continued coverage of an external insulin pump and supplies requires that the beneficiary be seen and evaluated by the treating physician at least every 3 months. In addition, the external insulin infusion pump must be ordered and follow-up care rendered by a physician who manages multiple beneficiaries on continuous subcutaneous insulin infusion therapy and who works closely with a team including nurses, diabetic educators, and dieticians who are knowledgeable in the use of continuous subcutaneous insulin infusion therapy. You can find this rule in Local Coverage Determination (LCD): External Infusion Pumps (L33794) - Effective January 1, 2020.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.