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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 for claims with dates of service on or after January 1, 2023, a non-adjunctive continuous 
glucose monitor (CGM) must be billed with code E2103. Code E2103 describes a non-adjunctive CGM that 
meets the requirements of the durable medical equipment (DME) benefit. 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 
Healthcare Common Procedure Coding System (HCPCS) code E2103. You can find this information in the 
Local Coverage Article: Glucose Monitor - Policy Article (A52464). 
 
The rules say that a Freestyle Libre 3 is not specified as a product that may be billed using code E2103 prior to 
June 15, 2023. You can find this information in the Product Classification List (PCL) on the Pricing Data 
Analysis, and Coding (PDAC) contractor website 
(https://www4.palmettogba.com/pdac_dmecs/searchProductClassificationResults.do?manufacturer=&codeDeci
sion=k0554&productName=&modelNumber=&classification=). 
 
The rules state that to be eligible for coverage of a continuous glucose monitor (CGM) and related supplies, the 
beneficiary must meet all of the following initial coverage criteria (1)-(5): 
 
1. The beneficiary has diabetes mellitus; and, 
2. The beneficiarys treating practitioner has concluded that the beneficiary (or beneficiarys caregiver) has 
sufficient training using the CGM prescribed as evidenced by providing a prescription; and, 
3. The CGM is prescribed in accordance with its Food and Drug Administration (FDA) indications for use; 
and, 
4. The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the 
criteria below: 
   A. The beneficiary is insulin-treated; or, 
   B. The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the 
following: 
      -     Recurrent level 2 hypoglycemic events that persist despite multiple attempts to adjust 
            medication(s) and/or modify the diabetes treatment plan; or,       -     A history of one level 3 hypoglycemic event characterized by altered mental and/or physical state 
requiring third-party assistance for treatment of hypoglycemia 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare-
approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria (1)-
(4) above are met. 
 
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
The rules also say a standard written order (SWO) must be communicated to the supplier prior to claim 
submission. For certain items of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), a 
written order is required prior to delivery (WOPD) of the item(s) to the beneficiary (see below). 
 
A SWO must contain all of the following elements: 
 Beneficiary's name or Medicare Beneficiary Identifier (MBI) 
 Order Date 
 General description of the item 
o The description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a 
HCPCS code narrative, or a brand name/model number 
o For equipment - In addition to the description of the base item, the SWO may include all concurrently 
ordered options, accessories or additional features that are separately billed or require an upgraded code (List 
each separately). 
o For supplies  In addition to the description of the base item, the DMEPOS order/prescription may 
include all concurrently ordered supplies that are separately billed (List each separately) 
 Quantity to be dispensed, if applicable 
 Treating Practitioner Name or NPI 
 Treating practitioner's signature 
 
You can find this information in the Local Coverage Article (LCA): Standard Documentation Requirements for 
All Claims Submitted to DME MACs (A55426). 
 
Signatures must comply with the CMS signature requirements outlined in the Medicare Program Integrity 
Manual (CMS Pub.100-08), Chapter 3, Section 3.3.2.4. Signature and date stamps are not allowed.  
 
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.