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 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 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 Autonomic function testing is covered as reasonable and necessary when used as a diagnostic tool to evaluate symptoms indicative of vasomotor instability, such as hypotension, orthostatic tachycardia, and hyperhidrosis after more common causes have been excluded by other testing, and the ANS testing is directed at establishing a more accurate or definitive diagnosis or contributing to clinically useful and relevant medical decision making for one of the following indications:
1. To diagnose the presence of autonomic neuropathy in a patient with signs or symptoms suggesting a progressive autonomic neuropathy.
2. To evaluate the severity and distribution of a diagnosed progressive autonomic neuropathy.
3. To differentiate the diagnosis between certain complicated variants of syncope from other causes of loss of consciousness.
4. To evaluate inadequate response to beta blockade in vasodepressor syncope.
5. To evaluate distressing symptoms in a patient with a clinical picture suspicious for distal small fiber neuropathy in order to diagnose the condition.
6. To differentiate the cause of postural tachycardia syndrome.
7. To evaluate change in type, distribution or severity of autonomic deficits in patients with autonomic failure.
8. To evaluate the response to treatment in patients with autonomic failure who demonstrate a change in clinical exam.
9. To diagnose axonal neuropathy or suspected autonomic neuropathy in the symptomatic patient.
10. To evaluate and treat patients with recurrent unexplained syncope to demonstrate autonomic failure, after more common causes have been excluded by other standard testing.
Limitations:
Syndromes of autonomic dysfunction for which ANS might add valuable clinical information are relatively rare. Generally, only after excluding more common causes of autonomic signs or symptoms (e.g., hypotension, hyperhidrosis, and orthostatic tachycardia) may formal autonomic testing be indicated to exclude or confirm rarer autonomic disorders. The following indications are considered NOT medically reasonable and necessary and will not be covered:
1. Patient screenings without signs or symptoms of autonomic dysfunction, including patients with diabetes, hepatic or renal disease.
2. Testing for the sole purpose of monitoring disease intensity or treatment efficacy in diabetes, hepatic or renal disease.
3. Testing where the results are not used in clinical decision-making and patient management.
You can find this rule in the Local Coverage Determination (LCD): Autonomic Function Tests (L35395) effective November 14, 2019.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.