Medicare Part B CGM Requirements: Do You Qualify in 2025?

Last updated: January 2025

Understanding Medicare Part B CGM requirements doesn’t have to be complicated. If you’re a senior with diabetes wondering if you qualify for a Continuous Glucose Monitor (CGM) through Medicare in 2025, you’re in the right place. We’ll walk you through the updated requirements step-by-step.

This article provides general information about Medicare coverage and is not medical advice. Always consult your healthcare provider and verify coverage with Medicare directly.

Do You Meet Medicare Part B CGM Requirements in 2025?

Medicare has simplified CGM coverage requirements for 2025, making it easier for many seniors to qualify. Here’s what you need to know:

Basic Qualification Checklist:

✓ You have Medicare Part B coverage
✓ You have been diagnosed with Type 1 or Type 2 diabetes
✓ You meet with your doctor in person or via telehealth at least every 6 months
✓ You or your caregiver can operate the CGM device

💡 Important Update: As of 2025, Medicare no longer requires you to test your blood sugar 3 times daily to qualify for CGM coverage.

Treatment Requirements – You Must Meet ONE of These:

To qualify for CGM coverage, you must either:

Option 1: Use insulin for diabetes management (any frequency), OR

Option 2: Have documented problematic hypoglycemia:

• 2 or more Level-2 episodes (blood sugar below 54 mg/dL), OR
• 1 or more Level-3 episode (requiring assistance from others)

Step-by-Step Guide to Getting CGM Coverage

Follow these steps to secure your Medicare CGM coverage:

1. Schedule a doctor’s appointment (in-person or telehealth)
2. Bring documentation of your diabetes management
3. Discuss CGM options with your healthcare provider
4. Get proper documentation of qualifying conditions
5. Obtain a prescription for a Medicare-approved CGM

Medicare covers both the CGM device (E2103) and monthly supplies (A4239) when requirements are met.

Breaking Down Each Requirement

1. Medicare Part B Coverage

What it means: You must be enrolled in Medicare Part B (medical insurance)

How to verify:

• Check your red, white, and blue Medicare card
• Look for “Part B” coverage dates
• Call 1-800-MEDICARE if unsure

Common issue: Some people only have Part A (hospital insurance)

2. Diabetes Diagnosis

Qualifying diagnoses:

• Type 1 diabetes (any age)
• Type 2 diabetes (insulin or non-insulin treated)
• Other forms of diabetes (consult your doctor)

What Medicare needs:

• Official diagnosis in medical records
• ICD-10 codes (E10.x for Type 1, E11.x for Type 2)
• Documentation from treating physician

3. Regular Medical Visits

Frequency required: Every 6 months minimum

Acceptable visit types:

• In-person appointments
• Telehealth visits (video or phone)
• Visits with primary care or endocrinologist

📅 Pro tip: Set calendar reminders for your 6-month check-ups to maintain continuous coverage.

4. Ability to Use CGM

What Medicare looks for:

• You can apply sensors
• You can read/understand data
• OR a caregiver can help

Not required:

• Technical expertise
• Smartphone proficiency
• Perfect vision or dexterity

Understanding the Treatment Requirements

Option 1: Insulin Use

Any insulin use qualifies:

• Multiple daily injections
• Once-daily long-acting insulin
• Insulin pumps
• Sliding scale insulin

Examples that qualify:

• “I take Lantus once daily”
• “I use Humalog with meals”
• “I’m on 70/30 insulin twice daily”

Option 2: Problematic Hypoglycemia

Level 2 Hypoglycemia (need 2 episodes):

• Blood sugar below 54 mg/dL
• Documented in medical records
• Can self-treat but significantly low

Level 3 Hypoglycemia (need 1 episode):

• Required help from another person
• May include unconsciousness
• Often involves ER visits or glucagon use

Real Senior Success Stories

Mary’s Qualification Story

Mary, 72, Type 2 Diabetes “I don’t use insulin, but I had two scary low blood sugar episodes last year – one at 48 and another at 51. My doctor documented these, and I qualified for my FreeStyle Libre!”

Robert’s Experience

Robert, 69, Type 1 Diabetes “I’ve used insulin for 30 years. Qualifying was simple – my insulin use alone met the requirements. The whole process took about 2 weeks.”

Helen’s Journey

Helen, 75, Type 2 Diabetes “My neighbor had to help me during a severe low. That one Level 3 episode qualified me for CGM coverage. I wish I’d known sooner!”

Documentation You’ll Need

Medical Records Should Include:

• Diabetes diagnosis date and type
• Current medications list
• History of blood sugar control
• Any hypoglycemic events
• Recent A1C results

For Hypoglycemia Documentation:

• Specific blood glucose readings
• Dates of episodes
• Emergency room records (if applicable)
• Witness statements (for Level 3)
• Glucagon administration records

Common Questions About Medicare CGM Coverage

What Does Medicare Part B Cover for CGM?

When you qualify, Medicare typically covers:

• 80% of the approved amount for your CGM device
• 80% of monthly supplies (sensors, transmitters)
• Replacement devices when medically necessary

How Often Do I Need to See My Doctor?

Medicare requires:

• Initial visit (in-person or telehealth) for CGM prescription
• Follow-up visits every 6 months to maintain coverage

Which CGM Brands Are Covered?

Medicare covers therapeutic CGMs including:

• FreeStyle Libre 2
• FreeStyle Libre 3
• Dexcom G6
• Dexcom G7

Cost Considerations

Your out-of-pocket costs typically include:

• Medicare Part B deductible ($240 in 2025)
• 20% coinsurance for approved amounts
• Any additional costs if your supplier doesn’t accept assignment

Cost Example:

• Monthly CGM supplies: $300 (Medicare-approved amount)
• Medicare pays: $240 (80%)
• You pay: $60 (20%)
• With Medigap: Often $0

What If You Don’t Qualify Yet?

If you’re close but don’t qualify:

No insulin or hypoglycemia:

• Discuss with doctor about blood sugar patterns
• Document any concerning lows
• Consider if insulin might help your control

Haven’t seen doctor recently:

• Schedule appointment immediately
• Telehealth counts!
• Establish regular visit schedule

Not on Medicare Part B:

• Enroll during appropriate period
• May face late enrollment penalty
• Consider if employer coverage coordinates

Step-by-Step Application Process

Week 1: Preparation

1. Gather medical records
2. List all diabetes medications
3. Document any low blood sugars
4. Schedule doctor appointment

Week 2: Doctor Visit

1. Discuss CGM benefits
2. Review qualification criteria
3. Get examination and documentation
4. Receive CGM prescription

Week 3: Supplier Contact

1. Choose Medicare-approved DME supplier
2. Submit prescription and documentation
3. Complete any required forms
4. Schedule training if needed

Week 4: Approval and Delivery

1. Receive approval notification
2. CGM ships to your home
3. Begin using your CGM
4. Schedule follow-up appointment

Tips for a Smooth Approval Process

Do:

✓ Keep all diabetes-related medical records
✓ Document blood sugar patterns
✓ Maintain regular doctor visits
✓ Choose experienced DME suppliers
✓ Ask questions if confused

Don’t:

✗ Wait for perfect documentation
✗ Skip doctor appointments
✗ Assume you don’t qualify
✗ Give up after one try
✗ Forget 6-month follow-ups

Medicare Advantage Considerations

If you have Medicare Advantage:

• Same basic requirements apply
• May need prior authorization
• Could have preferred suppliers
• Might offer additional benefits
• Check plan-specific rules

Getting Help and Support

Free Resources:

• SHIP counselors: 1-800-MEDICARE
• Diabetes educators at local hospitals
• Medicare.gov coverage information
• Senior center Medicare workshops

Questions for Your Doctor:

1. “Do I meet Medicare’s CGM requirements?”
2. “Can you document my qualifying condition?”
3. “Which CGM do you recommend for me?”
4. “Will you support my 6-month follow-ups?”

Your Next Steps

Ready to check if you qualify? Take action today:

This Week:

☐ Review the requirements above
☐ Check your Medicare Part B status
☐ Gather diabetes medical records
☐ List your medications

Next Week:

☐ Schedule doctor appointment
☐ Discuss CGM options
☐ Get prescription if qualified
☐ Contact DME supplier

This Month:

☐ Complete application process
☐ Receive your CGM
☐ Start monitoring
☐ Feel more confident!

The Bottom Line

Medicare Part B CGM requirements in 2025 are simpler than ever:

• No more 3-times-daily testing requirement
• Insulin use OR hypoglycemia qualifies you
• Regular doctor visits keep coverage active
• 80% coverage reduces your costs significantly

Don’t let confusion prevent you from getting this life-changing technology. If you have diabetes and Medicare Part B, you may already qualify!

Need Help Understanding Your Medicare CGM Eligibility?

Our team of Medicare specialists is here to help you navigate the requirements and get the coverage you deserve.

Call Now: 727-831-3729

Free eligibility check and personalized guidance