Current Eligibility Requirements for CGM Coverage Are Harmful, Costly, and Unjustified.

Abstract

Despite ongoing advances in medications, insulin delivery systems, and glucose monitoring technologies, diabetes control remains suboptimal in many individuals with this disease.1 In addition to the clinical consequences resulting from poor control is the ever-increasing financial burden on individuals, health systems, and society.2 In its latest report, the American Diabetes Association (ADA) estimated the total estimated cost of diagnosed diabetes in 2017 to be $327 billion.2 Although the direct cost of treating complications (hospitalizations, emergency room visits, and nondiabetes prescription medications) and the indirect costs associated with lost/reduced productivity account for ∼73.1% of the total diabetes cost, many public and private payers continue to focus much of their cost-cutting efforts on reducing the costs of diabetes supplies, which account for only 1.1% of the total cost. Examples of these questionable efforts can be found in the restrictive eligibility criteria for coverage of continuous glucose monitoring (CGM). Specifically, the requirements are that eligible individuals must have type 1 diabetes (T1D) and be able to document routine performance of at least four fingerstick blood glucose tests per day. The Centers for Medicare and Medicaid Services (CMS) explicitly requires this level of testing for Medicare beneficiaries to qualify for CGM coverage, as do 11 of 36 state Medicaid programs that provide CGM coverage. Requiring documentation of >4 blood glucose tests per day is clearly enigmatic given that the Medicare coverage policy only pays for three test strips per day for insulin-treated beneficiaries. Although Medicare coverage includes both T1D and intensively treated type 2 diabetes (T2D), many state Medicaid programs do not match such coverage. A comprehensive Internet search found that 13 state programs limit CGM use to individuals with T1D and documented history of 4 × /day blood glucose testing (Table 1). Three programs cover both T1D and insulin-requiring T2D but with the minimum blood glucose monitoring restriction. Four programs cover T1D with no blood glucose monitoring restriction, and only one state covers both type 1 and insulin-requiring diabetes with no blood glucose restriction. Eligibility for CGM in the remaining 14 State Medicaid programs is not specified or accessible according to our Internet search. Table 1. Medicaid Coverage for Continuous Glucose Monitoring Use