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Understanding Medicare Coverage for Continuous Glucose Monitors

A continuous glucose monitor (CGM) is a small device that tracks blood sugar levels throughout the day and night. Instead of pricking your finger multiple times daily, a CGM uses a tiny sensor placed under the skin to measure glucose readings automatically. The sensor sends information to a receiver or smartphone app, giving you real-time updates about your blood sugar patterns.

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Dexcom is one of the major CGM manufacturers. Their devices are called Dexcom G6, Dexcom G7, and other models. Medicare has made decisions about which CGM devices it will cover and under what circumstances. This matters because CGMs can cost several hundred dollars per month without insurance coverage, making them unaffordable for many people.

Medicare coverage for CGMs has evolved significantly over the past several years. The coverage policies determine whether your device costs, supplies, and replacements are paid for through your Medicare benefits or whether you pay out of pocket. Different types of Medicare plans—Original Medicare, Medicare Advantage, and Medigap—may cover CGMs differently.

Understanding how Medicare covers CGMs helps you make informed decisions about your diabetes management. The coverage rules affect not just the initial device but also the ongoing costs for sensors, which need to be replaced regularly. A free informational guide about Medicare's CGM coverage policies can outline what these rules are and how they might apply to different situations.

Practical Takeaway: Before investing in a CGM device, learning about Medicare's specific coverage policies for that device can help you understand your potential out-of-pocket costs and whether the device fits your budget.

What Medicare's Dexcom Coverage Guide Contains

A free Medicare Dexcom coverage information guide typically provides information about several key topics related to how Medicare pays for these devices. The guide usually explains which Dexcom models Medicare covers, what the coverage includes, and what it does not include. This foundational information helps you understand the scope of Medicare's involvement in paying for your CGM device.

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The guide generally outlines the difference between Original Medicare (Medicare Part A and Part B) and Medicare Advantage plans (Part C). Original Medicare is run directly by the federal government, while Medicare Advantage plans are offered by private insurance companies. These two types of plans can have different rules about CGM coverage, and understanding those differences is important. For example, one type of plan might cover certain models while another type does not.

Most guides include information about what documentation or records your doctor may need to provide to support CGM coverage. This might include things like your diabetes diagnosis, current treatment methods, and medical records showing why a CGM would be medically necessary in your situation. Having this information in advance can help you understand what your healthcare provider might need to gather.

The guide typically explains the coverage process—what steps happen after a prescription is written, how suppliers work with Medicare to process coverage, and what timelines you might expect. It also often addresses common questions about things like sensor replacement costs, whether backup devices are covered, and how often you can obtain new equipment.

Practical Takeaway: Reading through a coverage information guide before talking to your doctor or Medicare helps you ask informed questions and understand the system better, making conversations with healthcare providers more productive.

Medicare Part B Coverage for CGM Devices

Medicare Part B is the portion of Original Medicare that covers outpatient medical equipment and supplies, including devices like continuous glucose monitors. For CGM coverage under Part B, the device must be prescribed by your healthcare provider, and the provider must document that the device is medically necessary for managing your diabetes.

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Medicare Part B typically covers CGM devices at 80% of the approved amount after you have met your annual deductible. This means Medicare pays for four-fifths of the cost, and you are responsible for paying the remaining 20%. However, the exact costs you pay depend on several factors, including whether you have additional insurance (like a Medigap policy) that helps cover the remaining 20%, and which supplier you use to obtain the device.

The documentation requirements for Part B coverage are specific. Your doctor must include information showing that you have diabetes and are using insulin (since CGM coverage under Part B traditionally required insulin use, though this has evolved in recent years). Your doctor must also document that you are managing your condition actively and that a CGM would provide medical benefit. Some guides explain what "medically necessary" means in this context and what evidence your doctor might present.

Part B also has rules about how often you can receive replacement sensors and supplies. A Dexcom sensor, for example, typically lasts 10 days and then needs to be replaced. Medicare has specific policies about how frequently replacement sensors can be covered, which affects your ongoing costs and the rhythm of obtaining new supplies. Understanding these replacement cycles helps you plan ahead.

Practical Takeaway: If you have Original Medicare Part B, knowing that devices are typically covered at 80% and that your doctor must document medical necessity helps you prepare for conversations with your healthcare team and understand your financial responsibility upfront.

Medicare Advantage and Private Plan Coverage Variations

Medicare Advantage plans (Part C) are offered by private insurance companies and must cover everything that Original Medicare covers, but they may have different rules about how they cover those services. Some Medicare Advantage plans may cover CGMs with different copay amounts, different approval processes, or different supplier networks. Other Medicare Advantage plans may have more or less generous coverage than Original Medicare.

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Each Medicare Advantage plan is unique, which means coverage for Dexcom and other CGMs can vary significantly from plan to plan, even within the same insurance company. One plan might require prior authorization before you can obtain a device, while another plan might not. Some plans might limit coverage to specific Dexcom models, while others cover all available models. These differences matter when you are comparing plans during open enrollment periods.

Many informational guides about Medicare coverage explain that you should contact your specific plan directly to learn about its particular coverage policies. While general information about Medicare's approach to CGM coverage applies broadly, your individual plan's rules determine what you actually pay. Plans also change their coverage policies from year to year, so even if you had a device covered one year, the coverage might be different the next year.

Some Medicare Advantage plans include supplemental benefits that are not part of Original Medicare. These might include things like fitness programs, meal delivery services, or specialized diabetes management programs. While these are not the same as covering the CGM device itself, they may provide additional support for managing diabetes overall. Understanding what your specific plan offers beyond basic coverage can help you use your benefits fully.

Practical Takeaway: If you are enrolled in or considering a Medicare Advantage plan, you need to contact that specific plan to learn its CGM coverage rules rather than relying on general Medicare information, since each plan sets its own policies.

Documentation, Prescriptions, and the Coverage Process

The process of obtaining a Dexcom through Medicare begins with a prescription from your healthcare provider. Your doctor must determine that a CGM is medically necessary for your diabetes care and must write a prescription for a specific model. The prescription provides the medical justification for why you need the device, and without it, Medicare will not cover the cost.

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After your doctor writes the prescription, you typically work with a Dexcom-approved supplier to process the order through Medicare. The supplier handles the interaction with Medicare on your behalf, checking coverage rules, calculating your costs, and arranging shipment. Many guides explain this three-way relationship between you, your doctor, and the supplier so you understand who is responsible for each step.

Documentation that your doctor may provide typically includes your diabetes diagnosis, your current treatment plan (such as insulin dosages), your blood sugar monitoring history, and information about any previous CGM use. The more detailed your medical history, the clearer it becomes to Medicare that the device is medically necessary. Some guides provide examples of the types of information that strengthen a coverage request.

The timeline for this process varies. Some claims are processed quickly, while others may take several weeks if Medicare or the plan requires additional information. During this time, you and your doctor should stay in communication with the supplier about the status of your claim. If there are delays or questions, the supplier can help address them. Understanding that this process takes time helps you plan ahead and arrange for alternative monitoring methods if needed while waiting for your device.

Practical Takeaway: Before your doctor writes a prescription, confirming with a Medicare-approved Dexcom supplier that your specific situation likely qualifies for