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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 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 code list in 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. 
 
Therapeutic CGM devices replace a standard home blood glucose monitor (HCPCS codes E0607, E2100, 
E2101) and related supplies (HCPCS codes A4233, A4234, A4235, A4236, A4244, A4245, A4246, A4247, 
A4250, A4253, A4255, A4256, A4257, A4258, A4259). Claims for a BGM and related supplies, billed in 
addition to an approved CGM device (code K0554) and associated supply allowance (code K0553), will be 
denied. Refer to the Coding Guidelines in the LCD-related Policy Article for additional information. 
 
All therapeutic CGM devices billed to Medicare using HCPCS code K0554 must be reviewed for correct 
coding by the Pricing, Data Analysis and Coding contractor (PDAC). Continuous Glucose Monitor systems 
that have not been reviewed and listed on the Product Classification List for HCPCS code K0554 will be 
denied as incorrect coding. Refer to the Coding Guidelines in the LCD-related Policy Article for additional 
information. 
 
Refill requirements do not apply to code K0553. Only one (1) unit of service of code K0553 may be billed to 
the DME MACs at a time. Refer to the Coding Guidelines in the LCD-related Policy Article for additional 
billing instructions. 
  
You can find this information in Medicare's Local Coverage Determination (LCD): Glucose Monitors 
(L33822). 
 
 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.