Medicare refusal for CGMS


(Kathleen) #1

I remain frustrated with Medicare refusing to pay for Medtronic Cgms and supplies. I was on this treatment prior to aging into Medicare. I appealed at the first level and was denied. I felt too confused and could not figure what to do next. I know there are guidelines but I found it difficult to follow those directions. I guess I needed more hand holding thru the appeals process. It seemed pointless to continue. I am discouraged because denials are more common. Successful appeals are few and are rarely given. Dexcom has succeeded in getting their cgms covered. I think it’s a matter of semantics or wording of the device use that prevents Medtronic’s from being covered. Can anyone shed light on if they got their CGMS covered or where CMS (Medicare) is on approving ALL CGMS.
Frustrated and running out of funds to pay out of pocket!!!


(joe) #2

hi @KAK1 Kathleen,

I saw this post and cannot answer directly, however, my experience with Medtronic customer service has always been good. When I ask them to determine eligibility and out-of-pocket costs they have always been helpful.

have you reached out to medtronic on this issue?

I can’t find an easy straight answer on Medtronic CGM coverage and Medicare, but as you said, they seem to cover Dexcom - what would happen if you switched?

good luck to you I hope @Dennis has more Medicare experience and can reply.


(Kathleen) #3

Medicare made a extremely narrow definition of what kind of CGMS it will cover. It will only cover a device that does NOT need a confirming fingerstick blood sugar. With Dexcom you can dose insulin from the result shown on the CGMS. Medtronic says you need to do a fingerstick blood sugar and dose according to it. I will soon be getting the newest Medtronic 670G system which independently monitors and controls basal rate. For this reason I do not wish to change. Unfortunately it seems that Medicare is not willing to pay for the best therapy, only a second rate one.


(joe) #4

@KAK1, the 670 uses a feedback CGM. it’s a CGM combined with a pump but it is a CGM nonetheless … if Medicare covers the 670 then you get your CGM and the case is closed. I just don’t see how Medicare would cover the MM 670… maybe it’s me? good luck to you.


(Jackie Le Grand) #5

Kathleen, you are correct, Medicare only covers Dexcom because it does not need the confirmatory fingerstick for dosing. Under the Medicare rules, they can only cover CGM that can be used for dosing. JDRF is working with the Medicare agency to improve coverage for CGMs, but at this time, only Dexcom is covered.


(tedquick) #6

The given reason that Medicare covers ONLY the Dexcom G5, and now the Freestyle Libre CGMs is accuracy. The Dexcom and Libre systems have better accuracy than the Medtronic 670G. Dexcom tested as being 9.9% accurate, while the Medtronic tested at something like 11.9% accurate.
Point is that the Dexxcom, and more recently the Libre, are more ACCURATE than any fingerstickk meter across the board, so they can justify paying ONLY for the more accurate system.
That’s why you won’t have to verify the CGM reading via a fingerstick. Also I’ve talked to people who use both Dexcom G5 and Medtronic CGMs, and the Dexcom is easier to use, more reliable, as well as longer lasting. Pretty much the same for the Libre, which was approved more recently. Medtronic sensors seem to fail all too often, while Dexcom G5s usually carry on as long as expected, a BIG difference for the user.


(Kathleen) #7

Thanks for the update. Just paid $304.00 out of pocket for a month supply of Medtronic G3 sensors. Soooo crazy. I need to learn more about switching. Just started 607. It’s pretty good. My A1C dropping and time in target rate increasing. A lot good about it. I sure would like the inaccuracy rate to improve.


(joe) #8

@tedquick hi Ted, that’s not entirely true. there is no CGM more accurate than a finger stick. think about it, our finger stick meters are +/-20% accurate… and you use that thing to calibrate the CGM… the CGM doesn’t even measure blood sugar it measures interstitial fluid which only correlates to blood sugar.

The dex and libre were not compared to the MM 670, which is the latest generation CGM, in any clinical I can find (online - alas that’s all I have) the so there is no direct accuracy measurement argument between the two (or 3) - at least for now.

picayune? maybe, but CGM has a long way to go. cheers!


(Dennis J. Dacey, PwD) #9

Another factor to consider is the accuracy of BG meters - we know that extensive accuracy testing has been done on various CGM and that there are now some sensors that have been proven to be extremely accurate. And should we be more concerned about the amount of glucose traveling about in blood of the glucolse levels resident in our bodies.

The current USA standard for a BG meter is to have at least 85% of readings to be within 15 mg/dl accuracy - not very reassuring. The Diabetes Technology Society [The DCT] has recently published findings of meter accuracy, 18 commonly used meters in the US.

following is a link to that study - is your meter listed? https://www.diabetestechnology.org/surveillance.shtml


(tedquick) #10

Perhaps you didn’t see the report at:


and I qute:
CGM accuracy is measured as MARD (mean absolute relative difference between CGM readings and blood glucose readings). This is an error metric – lower MARD is better.

CGM system MARD
Dexcom G5
Dexcom 505 AP (USA) 9% officially 1
Dexcom G4 original algorithm 13.00% officially 2
12.60% in the test by IDS

Medtronic Enlite 13.60% officially 3
18.66% in a test by IDS

Abbott Freestyle Navigator 2 11% officially
Abbott Freestyle Libre 11,4% 4
References:
1 J Diabetes Sci Technol. 2015 Mar;9(2):209-14. doi: 10.1177/1932296814559746. Epub 2014 Nov 3.
2 Diabetes Technol Ther. 2013 Oct;15(10):881-8. doi: 10.1089/dia.2013.0077. Epub 2013 Jun 18.
3 Diabetes Technol Ther. 2014 May;16(5):277-83. doi: 10.1089/dia.2013.0222. Epub 2014 Apr 7.
4 Diabetes Technol Ther. 2015 Nov;17(11):787-94. doi: 10.1089/dia.2014.0378. Epub 2015 Jul 14.

Yes, it IS measuring interstitial fluid glucose rather than blood glucose, but the results show it more accurate than bg meters, as I said before. This is measured in terms of MARD, which makes the distinction of which fluid is tested moot.


(joe) #11

and I quote

this is the part that’s wrong. NO CGM is more accurate than a fingerstick blood glucose reading. it can’t be. the CGM is calibrated by your fingerstick blood glucose meter and therefore cannot be more accurate then the calibrating device.

@tedquick no one is saying that dex and maybe libre have decent accuracy … but the overall accuracy, repeatability , and reliability have a lot to be desired. How about a CGM that actually reads glucose levels in blood? How about one that doesn’t need calibration? I would even be happy about a fingerstick meter that had better accuracy than the +/-20% as required. anyway - this isn’t about arguing, this is about someone mistakenly thinking a CGM is more accurate than a finger stick blood glucose meter. @tedquick

Cheers!


(tedquick) #12

Dexcom is saying that the G6 now under development shouldn’t need calibration, though of course that remains to be proven and passed by the authorities.


(agate) #13

I’m turning 65 in a few months and am exploring Medicare issues. I am on the Medtronic 670g pump. Medtronic confirmed Medicare does not cover the cgm sensors, and they quoted a discounted rate for the sensors for people having to pay out-of-pocket. The discounted rate quoted is $304.15/box (box of 5 Guardian Sensors); the normal rate is $553.00/box. So a year of sensors would be approximately $3,163.16 (52 wks/yr divided by 5 sensors/box = 10.4 boxes X $304.15/box = $3,163.16.
That’s a significant out-of-pocket cost. It makes me wonder if there is any combination of Medicare-covered cgms (the Dexcom or Libre) with a certain pump that could be almost as good as the 670g. I realize it would not be a closed-loop setup. Does anyone have feedback on that approach? Thanks!
(By the way, I just passed 50 years w/ T1D, and this 670g is the best technology and control that I’ve ever had. It is the first pump I’ve ever used, though.)


(Dennis J. Dacey, PwD) #14

Hi @agate, welcome to Medicare and welcome to 50 years - will you be joining the Joslin Medalist Group - a discussion group reserved for those of us who have lived with diabetes for 50 or more years.

The information you received about CGM coverage under Medicare is correct - unfortunately. Just this morning I was speaking with a Dexcom Representative [at a JDRF fundraising walk] and she told me that the Dexcom G6 is currently being “examined” by Medicare for coverage. The G6 has proved more accurate than the G5 and the 6 doesn’t require any calibration.

The G5 is currently fully integrated with the Tandem t-slim pump and the t-slim pump software will be updated via internet to integrate with the G6. My [current] choice for a new pump combination is the t-Slim and G6 as soon as Medicare allows my to upgrade from 10+ year old technology. I’ve always used MiniMed [Medtronic] pumps.

I suggest that if you are going to make a change, do that BEFORE going on Medicare. My pump warranty expires next month but Medicare will not pay for an upgrade for another 12 months - at soonest; Medicare did the same to me five years ago and even at that would not permit current technology.


(Kathleen) #15

I too am on Medicare wearing a 670G with Guardian 3 sensors. I was able to participate in the pathways upgrade program. Your pricing of the sensors is spot on. It’s tough to balance $$ but the pump and Automatic guided basal rate has greatly improved my time in the target zone. I am actually looking forward to my next A1C!! I haven’t called them yet, but I am told that United healthcare has a Medicare Advantage plan that may cover sensors. I will do the cost breakdown to see if it is worth changing to an advantage plan. So many things to consider, drugs, providers, other items covered. So perhaps you would like to investigate this possibility PS. I’m three years from joining the 50 year club!


(Guy) #16

Hi All,

I am using the 670g pump and was using the Guardian 3 CGM until I retired and am using Medicare for my insurance coverage. I had some great experiences followed by some really not such great experiences with the 670g auto mode feature. I have switched to the Dexcom 5 as my CGM and have been pleasantly surprised with how much easier it is for me to monitor my glucose levels. The sense I have from communicating with Medtronic reps is that this company is not doing much to obtain Medicare coverage. Dexcom on the other hand is already diligently working to obtain Medicare coverage for the Dexcom 6. As I understand it a decision on this by Medicare is expected this coming Autumn. If I could, I would likely switch to the Tandem T Slim to replace the 630g insulin pump but this would not be covered by Medicare since my 670g pump is still under warranty. While I think the 670g pump is too big I am OK with keeping it as my insulin delivery device while using the Dexcom 5. I am be curious if there is anyone else using the JDRF TypeOne Community Forum who is in the same situation and what you think about changing from Medtronic to a Dexcom CGM system.


(Janice) #17

Medicare approved the Dexcom CGM as you have been told, and after using the Dexcom Cgm even before it was approved, I wouldn’t use any other. It’s I simple to use, I really like it, it works and the whole reason I went that way was because of it’s simplicity and the alarms… No ssymptomology any more and I needed something I could rely on. Hope this helps, bye jan


(BeccaGae) #18

I used the SofSensors, then the Enlites from MiniMed… then I went to Dexcom on the G4 then G5… that was the BEST decision I could have EVER made!
MiniMed is NOT TRYING to get Medicare to cover their sensors. I even ASKED if they are or would. They get just over $300 cash per box of their Guardian sensors… Medicare would pay them just about $175-200 a box… it is not worth it for them to get it Medicare approved… Dexcom has a deal with Medicare. And the Monthly subscription is $251.11… (or $753.33 quarterly) for 5 sensors, 150 Contour Next Strips, 100 Lancets and every 3 months you get a new transmitter. When you first sign up you get a G5 receiver and a Contour Next One meter kit. However after Medicare pays, your copay is $50.22 or 20%. (You are allowed to order every 30 Days).


(Dennis J. Dacey, PwD) #19

Hi Becca @beccagae, that WAS the plan for Medicare beneficiaries when first implemented in 2017 but that is not the way it is now.
The current Medicare “kit” when my prescription was approved July 2018 now includes the G5 Mobile Receiver, four (4) sensors and one transmitter; my out-of-pocket cost with Medicare Complete was $0.00. I am permitted to reorder sensors every four weeks - but although I put in my reorder in sufficient time for four 7-day sensors, my last order arrived [as scheduled by supplier] four weeks and three days after I began using the order previously received.
I’m not complaining now, I certainly appreciate what I have - especially toe extremely useful Clarity reports.