Continuous Glucose Monitors and Potential Audit Risk with PHE Ending

As the COVID-19 Public Health Emergency (PHE) declaration comes to an end on May 11, 2023, preparing for some changes to current flexibilities, actions and waivers that have been in place since COVID-19 began is crucial. While clinical indications for Continuous Glucose Monitors (CGMs) have not been enforced by Medicare during the PHE, PAAS National® advises pharmacies to take special precaution for any patients who obtained a CGM during this time.

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PAAS questioned Noridian and CGS on this topic:

For beneficiaries who obtained a CGM during the PHE (when clinical indications for coverage of CGMs was not enforced), will those beneficiaries be grandfathered in, or will they need to meet the current coverage criteria?

While awaiting Noridian’s response, CGS responded that they are awaiting an answer from CMS for this exact question. Once the DME MACs receive direction from CMS, they will email notifications to suppliers. The MACs will also be hosting webinars, ask-the-contractor (ACT) teleconference calls and post topics under the Education section on their websites to address the end of the PHE.

PAAS Tips:

  • If a patient received a CGM during the PHE, PAAS suspects effective May 12, 2023, these patients will need to meet Medicare coverage criteria and may not be grandfathered in
  • See the April 2023 Newsline article, A Documentation Checklist for Continuous Glucose Monitor Claims for Medicare coverage requirements, updated as of 4/16/2023
  • Run an internal report for patients utilizing a CGM that was paid for by Medicare
  • If the patient IS on insulin, then they meet Medicare guidelines for coverage of a CGM if they continue to have a visit with their provider every six months to document CGM compliance
  • If the patient is NOT on insulin, proactively reach out to the provider’s office to obtain medical records to support the patient has a history of problematic hypoglycemia (see LCD for details)
    • If the medical records do not support hypoglycemia, we would suggest reaching out to the provider and moving this patient back to a Blood Glucose Monitor (BGM) to lessen audit risk and payment denial
  • Watch for updates on the DME MAC websites
  • Review the Local Coverage Determinations (LCD) and Policy Articles (PA)
  • Utilize the Dear Physician Letter created by Medicare to assist the treating practitioner on what elements need to be in the beneficiary’s medical record to support initial and continued coverage as well as medically necessity

Jennifer Ottman, CPhT