Fact Check: Are cgms covered by insurance?

Are Continuous Glucose Monitors Covered by Insurance?

Introduction

The claim that continuous glucose monitors (CGMs) are covered by insurance is a topic of significant interest for individuals managing diabetes. CGMs are devices that allow for real-time monitoring of blood glucose levels, which can improve diabetes management. However, the extent of insurance coverage for these devices can vary widely based on factors such as the type of diabetes, the specific insurance plan, and the medical necessity criteria set by insurers.

What We Know

1. Medicare Coverage: Medicare provides coverage for therapeutic CGMs, but specific eligibility requirements must be met. According to the Centers for Medicare and Medicaid Services (CMS), individuals must have type 1 diabetes and demonstrate routine blood glucose monitoring through fingerstick tests to qualify for coverage 29.

2. Insurance Variability: Many health insurance plans, including private insurers, may cover CGMs, but coverage is not universal. GoodRx notes that coverage can depend on the specific plan and whether the device is deemed medically necessary 34.

3. Eligibility Criteria: According to a study published in the Journal of Diabetes Science and Technology, eligibility for CGM coverage often includes documentation of frequent blood glucose testing and a diagnosis of diabetes 1.

4. Cost Considerations: Even with insurance, CGMs can be expensive. GoodRx highlights that out-of-pocket costs can still be significant, depending on the insurance plan and any deductibles or copayments that apply 5.

5. Navigating Coverage: Resources such as the American Diabetes Association and various legal clarity organizations provide guidance on how to navigate insurance coverage for CGMs, indicating that understanding the specific criteria and processes is crucial for obtaining coverage 478.

Analysis

The evidence surrounding CGM insurance coverage is mixed and varies significantly based on the source.

• Credibility of Sources: The sources cited include government websites (Medicare), health organizations (American Diabetes Association), and consumer health platforms (GoodRx). Government sources like Medicare are generally reliable as they provide official guidelines and updates. However, consumer health platforms may have biases based on their target audience or potential partnerships with healthcare providers or manufacturers.

• Potential Bias: GoodRx and similar platforms may have a vested interest in promoting CGMs, as they often provide pricing information and may benefit from increased sales of these devices. This could lead to a bias in how they present coverage information.

• Methodological Concerns: The variability in coverage is often attributed to differing eligibility criteria among insurers. For example, while Medicare has specific requirements, private insurers may have different standards that are not as clearly defined. This lack of uniformity complicates the ability to make broad claims about CGM coverage.

• Conflicts of Interest: Some sources, particularly those affiliated with manufacturers of CGMs, may present information that favors the use of their products. For example, the FreeStyle Libre website discusses affordability but may not provide a comprehensive view of all costs associated with CGM use 10.

Conclusion

Verdict: Partially True

The claim that continuous glucose monitors (CGMs) are covered by insurance is partially true. Evidence indicates that Medicare does provide coverage for CGMs under specific conditions, particularly for individuals with type 1 diabetes who meet certain eligibility criteria. Additionally, many private insurance plans may also cover CGMs, but this coverage is not guaranteed and varies significantly based on the individual plan and medical necessity determinations.

However, the nuances of insurance coverage, including the variability in eligibility criteria and potential out-of-pocket costs, complicate the assertion that CGMs are universally covered. The evidence suggests that while some individuals may have access to coverage, others may face significant barriers, including high costs and differing requirements among insurers.

It is important to acknowledge the limitations in the available evidence, as much of it is based on varying interpretations of insurance policies and the specific circumstances of individual patients. The lack of uniformity in coverage across different insurers adds to the uncertainty surrounding this issue.

Readers are encouraged to critically evaluate information regarding CGM coverage and consult with their healthcare providers and insurance representatives to understand their specific coverage options and requirements.

Sources

1. Anderson, J. E. (2020). Current Eligibility Requirements for CGM Coverage Are ... Journal of Diabetes Science and Technology. Retrieved from PMC
2. Medicare. (n.d.). Therapeutic Continuous Glucose Monitors Coverage. Retrieved from Medicare.gov
3. GoodRx. (n.d.). Does Insurance Cover Diabetes Monitoring Devices? Retrieved from GoodRx
4. Legal Clarity. (n.d.). How to Get Continuous Glucose Monitors Covered by Insurance. Retrieved from Legal Clarity
5. GoodRx. (n.d.). How Much Does a Continuous Glucose Monitor Cost? Retrieved from GoodRx
6. Legal Clarity. (2025). Does Insurance Cover Continuous Glucose Monitors? Retrieved from Legal Clarity
7. Beyond Type 1. (n.d.). Why Won't My Insurance Cover a Continuous Glucose Monitor? Retrieved from Beyond Type 1
8. American Diabetes Association. (n.d.). CGM Insurance Coverage Look-Up Tool. Retrieved from ADCES
9. American Diabetes Association. (2023). FAQs on CGM Coverage Criteria Changes in Medicare. Retrieved from ADA
10. FreeStyle. (n.d.). Cost and Insurance Coverage | FreeStyle Libre US. Retrieved from FreeStyle