Wiki Medicare Coverage for upgrading to CGM

[JillMedicalBiller]

Hello! Does anyone know if Medicare will cover a patient's CGM if they are upgrading from a BGM within the five year period?
Or does that fall under the Reasonable Useful Lifetime Same and Similar policy?
Thank you for any input on this!

 

[CBLENNIE]

I don't believe that the patient transitioning to a CGM from BGM would be limited by the 5-year RUL rule. I think it is similar to a patient transitioning from a manual wheelchair to a PWC due to a change in the patient's condition or status. Of course, you have to make sure that the patient meets the criteria laid out for the medical necessity of a CGM per LCD L33822 Glucose Monitors, which is for the Idaho DME MAC Noridian. I see a ton of Part C appeals that are upheld by the QIC for denial of a CGM for patients because they don't meet the criteria listed in the LCD so be certain that the patient meets ALL of the criteria laid out in the LCD.

 

[JillMedicalBiller]

I don't believe that the patient transitioning to a CGM from BGM would be limited by the 5-year RUL rule. I think it is similar to a patient transitioning from a manual wheelchair to a PWC due to a change in the patient's condition or status. Of course, you have to make sure that the patient meets the criteria laid out for the medical necessity of a CGM per LCD L33822 Glucose Monitors, which is for the Idaho DME MAC Noridian. I see a ton of Part C appeals that are upheld by the QIC for denial of a CGM for patients because they don't meet the criteria listed in the LCD so be certain that the patient meets ALL of the criteria laid out in the LCD.

Thank you so much for your input on this!!