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CGM Candidate Selection Characteristics  

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Candidate selection characteristics include a variety of considerations from physical to general readiness.

Written by: ADCES staff and subject matter expert faculty

February 2024

 

Who should be prescribed a CGM?

Any of the following may be an indication for Personal CGM: Type 1 or Type 2 Diabetes.

  • Taking multiple daily injections of insulin
  • Using an insulin pump
  • Frequent hypoglycemia
  • Hypoglycemia unawareness
  • High degree of glycemic variability
  • Not achieving glucose targets  

The American Diabetes Association makes the following recommendation in its 2020 Standards of Medical Care in Diabetes16: “Use of technology should be individualized based on a patient’s needs, desires, skill level and availability of devices.” By offering a personal CGM program, providers can assess a patient’s needs, desires, and skill level and help them identify a CGM device that will work for them. The American Diabetes Association goes on to say that “Nonprofit websites can offer advice for providers and patients to determine the suitability of various options.”  

An example of a valuable not-for-profit website that can help both providers and people with diabetes make decisions as to the initial choice of device is DiabetesWise from Stanford University, funded by The Leona M. and Harry B. Helmsley Charitable Trust. 

Payor Considerations

The criteria set down by CMS in 2023

The Centers for Medicare & Medicaid Services (CMS) has expanded coverage for continuous glucose monitors (CGM). CGM services are now covered for all patients with diabetes who are treated with insulin or who have hypoglycemia. This coverage includes people with Type 1, Type 2 and gestational diabetes.   

CGM Coverage Criteria

To be eligible for coverage of a CGM and related supplies, the beneficiary must meet all of the following initial coverage criteria (1)-(5):

1. The beneficiary has diabetes mellitus 

2. The beneficiary’s treating practitioner has concluded that the beneficiary (or beneficiary’s caregiver) has sufficient training using the CGM prescribed as evidenced by providing a prescription 

3. The CGM is prescribed in accordance with its FDA indications for use 

4. The beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the criteria below:

a. The beneficiary is insulin-treated; or, 

b. The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the following:

Recurrent (more than one) level 2 hypoglycemic events (glucose <54mg/dL (3.0mmol/L)) that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan; or,

A history of one level 3 hypoglycemic event (glucose <54mg/dL (3.0mmol/L)) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia

5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare-approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria (1)-(4) above are met.

CGM Continued Coverage

Every six (6) months following the initial prescription of the CGM, the treating practitioner conducts an in-person or Medicare-approved telehealth visit with the beneficiary to document adherence (sic) to their CGM regimen and diabetes treatment plan.

Cost Implications of CGM Use in Type 2 Diabetes 

In the American Journal of Managed Care’s Evidence Based Diabetes Management, 2019, Kompala and Neinstein discuss that one study looked at long-term cost-effectiveness for CGM use in people with Type 2 diabetes based on HbA1c reduction, projecting decreased rates of diabetes-associated complications.“ Although we anticipate that HbA1 reduction through lifestyle changes by CGM users could prevent the addition of costly new medications or dose intensification of existing treatments, more study is needed to test this. This matters: Studies looking at HbA1c compared with health care costs have found significant impacts. In one case, a 1% decrease in A1C was associated with $685 to $950 per year lower total health care costs, and in another, a 1% increase in HbA1c was associated with a 7% increase in health care costs over the next 3 years.”

Patient Readiness for Use of Continuous Glucose Monitoring

Is your patient with diabetes ready to utilize continuous glucose monitoring technology?  Welsh notes, in his June 2018 Diabetes Technology & Therapeutics article, “Role of Continuous Glucose Monitoring in Insulin-Requiring Patients with Diabetes,” that it is important to set realistic expectations of CGM use to help avoid frustrations and disappointment. “CGM use should not be imposed on those who are unwilling to use it consistently or incapable of using it beneficially.” Comprehensive training on the device is important, both initially and ongoing, and will lead to the long-term success of the individual with the CGM. One strategy to assist the person with diabetes who is feeling uncertain if personal CGM is right for them would be to offer a short-term trial with professional CGM.   

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DISCLAIMERS: 

This site and its services do not constitute the practice of medical advice, diagnosis or treatment. Always talk to your diabetes care and education specialist or health care provider for diagnosis and treatment, including your specific medical needs. If you have or suspect that you have a medical problem or condition, please contact a qualified health care professional immediately. To find a diabetes care and education specialist near you, visit the ADCES finder tool.

ADCES and danatech curate product specifics and periodically review them for accuracy and relevance. As a result, the information may or may not be the most recent. We recommend visiting the manufacturer's website for the latest details if you have any questions.

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