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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 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 say that coverage of a continuous glucose monitor (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 Durable Medical Equipment (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: 
1. 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. 
2. 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. You can find this rule in 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.