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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 state that therapeutic continuous glucose monitors (CGMs) and related supplies are covered by 
Medicare when all of the following coverage criteria are met: 
  1. The beneficiary has diabetes mellitus, 
  2. The beneficiary is insulin-treated with multiple (three or more) daily administrations of insulin or a 
Medicare-covered continuous subcutaneous insulin infusion (CSII) pump, 
  3. The beneficiarys insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of 
blood glucose monitor (BGM) or CGM testing results, 
  4. 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 (1-3) above are met; and, 
  5. 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. 
 
You can find this information in the Local Coverage Determination (LCD): Glucose Monitors (L33822). 
 
The rules say for beneficiaries who exceed the usual utilization amounts of blood glucose monitoring (BGM) 
testing supplies, there must be sufficient information in the beneficiarys medical record to determine that: 
 The treating practitioner has had an in-person or Medicare-approved telehealth visit to evaluate the 
beneficiarys diabetes control; and, 
 The specific quantities of supplies ordered are reasonable and necessary; and, 
 The beneficiary is actually testing at a frequency that corroborates the quantity of supplies that have 
been dispensed (e.g., a specific narrative statement that adequately documents the frequency at which 
the beneficiary is actually testing or a copy of the beneficiary's log). 
 
For the in-person or Medicare-approved telehealth treating practitioner visit that is required as part of the initial 
provision of a CGM, there must be sufficient information in the beneficiarys medical record to determine that 
the beneficiary has diabetes mellitus (criterion 1), the beneficiary (or the beneficiary's caregiver) has received 
appropriate training in the use of the device as evidenced by a prescription (criterion 2), the CGM is being 
prescribed in accordance with Food and Drug Administration (FDA) indications for use (criterion 3), and the CGM is being prescribed to improve glycemic control for a beneficiary who is insulin treated or has a history 
of problematic hypoglycemia (criterion 4).  
 
For criterion 4B, the treating practitioners medical record must document the beneficiary has a history of 
problematic hypoglycemia consistent with one of the following pathways to coverage: 
1. Beneficiaries with non-insulin treated diabetes and a history of recurrent (more than one) level 2 
hypoglycemic events 
2.  
a. The treating practitioner must document at least one of the following in the medical record for 
each event:  
i. The glucose values for the qualifying event(s) (glucose <54mg/dL (3.0mmol/L)); or, 
ii. Classification of the hypoglycemic episode(s) as level 2 event(s); or, 
iii. Incorporate a copy of the beneficiarys BGM testing log into the medical record 
reflecting the specific qualifying events (glucose <54mg/dL (3.0mmol/L)); and, 
b. Documentation of more than one previous medication adjustment and/or modification to the 
treatment plan (such as raising A1c targets) prior to the most recent level two event. 
2. Beneficiaries with non-insulin treated diabetes and a history of at least one level 3 hypoglycemic event 
a. The treating practitioner must document at least one of the following in the medical record: 
i. The glucose value for the qualifying event (glucose <54mg/dL (3.0mmol/L)); or, 
ii. Classification of the hypoglycemic episode as level 3 event; or, 
iii. Incorporate a copy of the beneficiarys BGM testing log into the medical record 
reflecting the specific qualifying event (glucose <54mg/dL (3.0mmol/L)); and, 
b. An indication in the medical record that the beneficiary required third party assistance for 
treatment. 
 
For the in-person or Medicare-approved telehealth treating practitioner visit that is required as part of the 
ongoing provision of a CGM, there must be sufficient information in the beneficiarys medical record to 
determine that the beneficiary continues to adhere to their diabetes treatment regimen and use of the CGM 
device. 
 
You can find this information in the Local Coverage Article (LCA): Glucose Monitors (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.