| Medicare Coverage | Part B DME, 80% after deductible |
| Medicare Eligibility | Insulin use or hypoglycemia risk |
| Medicaid Coverage | Varies by state |
| Private Insurance | Prior auth usually required |
| Appeal Success Rate | ~50%+ overturned on appeal |
| Covered Devices | Dexcom G7, Libre 3, Medtronic Guardian |
Key Takeaways
- Medicare covers CGMs for people with diabetes who use insulin or have a history of hypoglycemia
- Medicaid coverage varies significantly by state
- Most private insurers cover CGMs for Type 1 diabetes; Type 2 coverage is expanding
- Prior authorization is almost always required
- Appeals are effective β over 50% of denied claims are overturned
Medicare CGM Coverage
Medicare classifies CGMs as Durable Medical Equipment (DME) under Part B. Since 2017, Medicare has covered therapeutic CGMs, and coverage was expanded in 2023 to include all people with diabetes using insulin.
Medicare Eligibility Requirements
- Diagnosed with diabetes mellitus
- Using insulin (any frequency) OR documented hypoglycemia risk
- Prescription from a treating physician
- Device must be ordered from a Medicare-enrolled DME supplier
Medicare Part B typically covers 80% of approved costs after the deductible. Patients pay the remaining 20%. Medigap plans may cover this gap. Medicare covers both the CGM device and ongoing sensors.
Medicaid CGM Coverage
Medicaid coverage is state-administered and varies widely. Most states cover CGMs for Type 1 diabetes; fewer than half cover them for Type 2. Always check your state's Medicaid formulary or contact your caseworker directly.
| Coverage Level | Typical State Criteria |
|---|---|
| Broad | All insulin users, Type 1 and 2 |
| Moderate | Type 1 only or intensive insulin therapy |
| Limited | Prior auth required, strict criteria |
Private Insurance CGM Coverage
Commercial insurers β including employer plans and ACA marketplace plans β increasingly cover CGMs, especially following updated clinical guidelines recognizing CGM as standard of care.
Common Private Insurance Requirements
- Type 1 diabetes diagnosis (most plans)
- Type 2 on basal-bolus insulin (many plans)
- HbA1c above a threshold (often 7.0β8.0%)
- Letter of medical necessity from prescribing physician
- Prior authorization renewed annually
How to Get Your CGM Covered
Step-by-Step Process
- Step 1: Get a CGM prescription from your endocrinologist or primary care doctor
- Step 2: Have your doctor submit a letter of medical necessity
- Step 3: Confirm your plan's preferred CGM brand (formulary)
- Step 4: Submit prior authorization through your supplier or pharmacy
- Step 5: If denied, file an appeal with supporting clinical documentation
CGM Brands and Insurance Compatibility
Dexcom G7, Libre 3, and Medtronic Guardian are the most commonly covered CGMs. Coverage tiers vary β some insurers cover one brand preferred over another. MDS Diabetes carries insurance-compatible CGM sensors and can help verify your coverage. Visit mdsdiabetes.com to browse sensors and check compatibility with your plan.
What to Do If You're Denied
Denials are common but not final. Request a written denial with the specific reason. Have your doctor provide peer-to-peer review or additional documentation. File an internal appeal, then an external independent review if needed. Patient advocacy organizations like JDRF offer free assistance navigating appeals.