Why Did Medicare Deny My CGM? Top 10 Reasons
Medical Disclaimer: This article provides general information about Medicare CGM coverage and denial reasons, including common Medicare deny CGM reasons. Always verify specific coverage details with Medicare or your healthcare provider.
Has Medicare denied your Continuous Glucose Monitor (CGM) coverage? You’re not alone. Understanding why Medicare might deny CGM coverage is the first step to getting the diabetes management tools you need. Let’s explore the top 10 reasons for Medicare CGM denials and what you can do about them.
The Most Common Reasons Medicare Denies CGM Coverage
Medicare has specific requirements for CGM coverage. Missing even one requirement can result in a denial. Here are the top reasons your CGM claim might be rejected:
1. Incomplete Documentation of Diabetes Diagnosis
Medicare requires clear documentation of Type 1 or Type 2 diabetes. Your medical records must show an official diagnosis with the correct ICD-10 code.
✓ Action Step: Ask your doctor to verify your diabetes diagnosis is properly documented in your medical records.
2. Missing Recent Doctor’s Visit
You must have had a face-to-face or telehealth visit with your healthcare provider within 6 months of your CGM request.
Good News: Medicare now accepts telehealth visits for CGM qualification. This makes it easier for seniors with mobility challenges to meet this requirement.
3. No Documentation of CGM Training
Your doctor must confirm that you or your caregiver has been trained to use the CGM system. The prescription typically serves as evidence of this training.
4. Insufficient Evidence of Need
As of 2025, you must meet one of these criteria:
- Currently using insulin
- Have documented problematic hypoglycemia:
- 2 or more Level-2 events (blood sugar below 54 mg/dL)
- OR 1 or more Level-3 event requiring assistance
5. Using the Wrong DME Supplier
Not all Durable Medical Equipment (DME) suppliers are Medicare-approved for CGM supplies. Using a non-approved supplier will result in automatic denial.
✓ Action Step: Verify your DME supplier is Medicare-approved before ordering.
6. Incorrect Diagnosis Codes
Your doctor must use the proper ICD-10 codes on your prescription. Common approved codes include:
- E10.9 (Type 1 diabetes)
- E11.9 (Type 2 diabetes)
- E11.65 (Type 2 diabetes with hyperglycemia)
7. Prior Authorization Not Obtained
Some Medicare Advantage plans require prior authorization before CGM coverage. Skipping this step leads to denial.
8. Frequency Limits Exceeded
Medicare covers specific quantities of CGM supplies:
- 1 receiver every 12 months
- 1 transmitter every 3 months
- Sensors based on manufacturer guidelines (typically monthly)
9. Missing Physician’s Written Order
A verbal prescription isn’t enough. Medicare requires a detailed written order from your healthcare provider that includes:
- Your diagnosis
- CGM brand and model
- Quantity and frequency of supplies
- Length of need
10. Outdated Medical Records
If your medical records don’t reflect your current condition or treatment plan, Medicare may deny coverage based on outdated information.
What to Do If Medicare Denies Your CGM
Don’t give up if Medicare denies your CGM coverage. Here are your next steps:
- Request a Written Denial: Get the official denial reason in writing from Medicare.
- Review the Specific Reason: Match the denial code to the list above to understand exactly what’s missing.
- Work with Your Doctor: Schedule an appointment to address any missing documentation or requirements.
- File an Appeal: You have the right to appeal Medicare’s decision. Most successful appeals involve correcting documentation issues.
- Get Expert Help: Consider working with a Medicare-approved DME supplier who specializes in CGM coverage.
Tips for Getting Approved the First Time
- Schedule regular doctor visits (at least every 6 months)
- Keep detailed blood sugar logs showing hypoglycemic events
- Ensure your doctor uses correct diagnosis codes
- Choose a Medicare-approved DME supplier
- Submit complete documentation upfront
Need Help with Medicare CGM Coverage?
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