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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 (1)-(5): met: 
1. The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for 
applicable diagnoses); 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 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 
a) Recurrent (more than one) level 2 hypoglycemic events (glucose less than 54mg/dL 
(3.0mmol/L)) that persist despite multiple (more than one) attempts to adjust 
medication(s) and/or modify the diabetes treatment plan; or, 
b) A history of one level 3 hypoglycemic event (glucose less than 54mg/dL (3.0mmol/L)) 
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 rule in the Local Coverage Determination (LCD): Glucose Monitors, L33822. For criterion 4B of LCD L33822, 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  
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 less than 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 less than 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 less than 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 less than 54mg/dL (3.0mmol/L)); and, 
b. An indication in the medical record that the beneficiary required third party assistance for 
treatment. 
You can find this rule in the Local Coverage Article for 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.