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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 home blood glucose monitors (BGMs) and continuous glucose monitors (CGMs) are covered 
under the Durable Medical Equipment (DME) benefit [Social Security Act 1861(s)(6)]. In order for a 
beneficiarys DME to be eligible for reimbursement, the reasonable and necessary (R&N) requirements set out 
in the related Local Coverage Determination (LCD) must be met. In addition, there are specific statutory 
payment policy requirements, discussed below, that also must be met. 
 
A non-adjunctive CGM can be used to make treatment decisions without the need for a stand-alone BGM to 
confirm testing results. An adjunctive CGM requires the user verify their glucose levels or trends displayed on 
a CGM with a BGM prior to making treatment decisions. On February 28, 2022, CMS determined that both 
non-adjunctive and adjunctive CGMs may be classified as DME. CGM devices that solely display results on a 
smartphone and do not have a stand-alone receiver or integration into an insulin infusion pump do not meet the 
definition of DME and will be denied as non-covered (no benefit). 
 
The supply allowance for supplies used with a CGM system (A4238, A4239) encompasses all items necessary 
for the use of the device and includes but is not limited to, CGM sensors and transmitters. For non-adjunctive 
CGMs, the supply allowance (A4239) also includes a home BGM and related supplies (test strips, lancets, 
lancing device, calibration solution, and batteries), if necessary. Supplies or accessories billed separately will 
be denied as unbundling. 
 
For adjunctive CGMs, the supply allowance (A4238) encompasses all items necessary for the use of the device 
and includes but is not limited to, CGM sensors and transmitters. Separate billing of CGM sensors and 
transmitters will be denied as unbundling. Code A4238 does not include a home BGM (Healthcare Common 
Procedure Coding System (HCPCS) codes E0607, E2100, E2101) and related BGM testing supplies (HCPCS 
codes A4233, A4234, A4235, A4236, A4244, A4245, A4246, A4247, A4250, A4253, A4255, A4256, A4257, 
A4258, A4259). These items may be billed separately, in addition to code A4238.   
 
Coverage of a CGM system supply allowance (code A4238 or A4239) is available for CGM systems when the 
beneficiary uses a stand-alone receiver or insulin infusion pump classified as DME to display glucose data. In 
addition, Medicare coverage is available for a CGM system supply allowance if a non-DME device (watch, smartphone, tablet, laptop computer, etc.) is used in conjunction with the durable CGM receiver (code E2102 
or E2103). The following are examples of this provision: 
 
Medicare coverage of a CGM supply allowance is available when a beneficiary uses a durable CGM receiver to 
display their glucose data and also transmits that data to a caregiver through a smart phone or other non-DME 
receiver. 
 
Medicare coverage of a CGM system supply allowance is available when a beneficiary uses a durable CGM 
receiver on some days to review their glucose data but uses a non-DME device on other days. 
 
If a beneficiary never uses a DME receiver or insulin infusion pump to display CGM glucose data, the supply 
allowance is not covered by Medicare. 
 
Smart devices are non-covered by Medicare because they do not meet the definition of DME (i.e., not primarily 
medical in nature and are useful in the absence of illness). Claims for smart devices must be billed using code 
A9270 (non-covered item or service). 
 
To be eligible for Medicare reimbursement, all CGM devices billed as E2103 must have received coding 
verification review by the Pricing, Data Analysis and Coding (PDAC) contractor and be listed on the Product 
Classification List (PCL) for HCPCS code E2103. Effective July 1, 2022, all CGMs billed to Medicare using 
HCPCS code E2102 must have received coding verification review by the PDAC contractor and be listed on 
the PCL for HCPCS code E2102. If a CGM system is billed using HCPCS E2102 or E2103 but the CGM 
system is not on the PCL for the particular HCPCS code, then the claim will be denied as incorrect coding. 
Products reviewed by the PDAC which do not meet the DME benefit category requirements must be coded as 
A9276, A9277, A9278, or A9279 and will be denied as non-covered (no Medicare Benefit). You can find these 
rules in the Local Coverage Article Glucose Monitor - Policy Article A52464. 
 
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.