Cigna Insurance To Cover Senseonics Eversense Cgm
Eliza Skoler
Cigna health insurance will now cover the 90-day implantable Eversense CGM for people with type 1 or type 2 diabetes who take insulin
Senseonics announced that Cigna insurance will now cover the Eversense, an implantable 90-day continuous glucose monitor . Cigna will cover Eversense for people with type 1 or type 2 diabetes who take insulin.Cigna is one of the largest health insurers in the United States, with 17 million members. This means that the Eversense will be covered for 17 million more people, in addition to the 150 million people who already have coverage through other insurance companies .Do you want Eversense but dont have coverage through a health plan? Learn about the $99 Senseonics Bridge Program.What is Eversense?Eversense is an implanted CGM a pill-sized sensor is inserted in the upper arm for 90 days, and an on-body transmitter sits on top of the skin to send real-time CGM data to a smartphone app . Other CGMs have on-body sensors that need to be replaced every 7-14 days. Eversense must be calibrated with two fingersticks twice per day.
Glutamic Acid Decarboxylase Autoantibodies
Aetna considers measurement of autoantibodies to GAD medically necessary for distinguishing type 1 from type 2 diabetes when the clinical history is ambiguous and the results of testing will influence patient management. Measurement of anti-GAD antibodies is also considered medically necessary in diagnosing stiff-person syndrome. Anti-GAD antibody measurement is considered experimental and investigational for predicting the onset of diabetes and for all other indications.
Does Medicare Pay For Dexcom G6
Dexcom G6® CGM System will be covered for Medicare beneficiaries, having met the category requirements for therapeutic CGM systems by the U.S. Centers for Medicare& Medicaid Services .
How much does Medicare cover for dexcom?
A: According to Dexcoms Medicare FAQ page, those covered by Medicare can expect to pay 20% of the costs of their G5 CGM, which is roughly $50 per month. Medicare will cover the remaining 80%.
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Predx Diabetes Risk Score
The PreDx® Diabetes Risk Score test is a multiple-biomarker test to identify high-risk individuals who might develop diabetes within 5 years. Using a proprietary algorithm combines seven biomarkers to quantify the risk of developing diabetes within 5 years. The model also includes age and sex. A diabetes risk score between 1 and 10 is calculated, with a higher score indicating an increased likelihood of developing diabetes within 5 years. Since the biomarkers are a combination of proteins and metabolites, they are measured using several different methods: ion-exchange high-performance liquid chromatography , chemiluminescent immunoassay , enzymatic , immuno-turbidometric assay , and an enzyme-linked immunosorbent assay . The PreDx DRS is used for patients who do not have type 2 diabetes but are at increased risk for developing this condition. Patients to be considered include those with impaired fasting glucose, metabolic syndrome, or other risk factors, including family history, age > 45 years, presence of obesity, coronary artery disease, hypertension, low high-density lipoprotein cholesterol , increased triglycerides, and belonging to an ethnic group with a higher prevalence of diabetes . Currently, two laboratories offer the PreDx DRS multibiomarker test. However, all testing is done at one of these facilities, Tethys Bioscience Inc.
Continuous Glucose Monitoring Devices
Aetna considers the short-term diagnostic use of continuous glucose monitoring devices medically necessary for persons with diabetes who have either of the following problems in controlling blood glucose level, unresponsive to conventional insulin dose adjustment:
Aetna considers the short-term diagnostic use of continuous glucose monitoring devices medically necessary to diagnose primary islet cell hypertrophy or persistent hyperinsulinemic hypoglycemia of infancy in persons with symptoms suggestive of recurrent hypoglycemia.For short-term diagnostic use, no more than 2 continuous glucose monitoring periods are considered medically necessary within a 12-month period.
Aetna considers experimental and investigational the long-term use of continuous glucose monitors for individuals with type 1a glycogen storage disease, persons with type 2 diabetes not using intensive insulin regimens, nesidioblastosis , neonatal hypoglycemia, and for monitoring blood glucose in non-diabetic persons following gastric bypass surgery because there is insufficient evidence of the clinical benefits of this approach for these indications.
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Use Of Outdated And Inappropriate Evidence Is The Fatal Flaw In Policy Decision
As demonstrated in the REPLACE and DIAMOND T2D studies, use of CGM in individuals with T2D who are treated with intensive insulin management confers significant clinical benefits. Moreover, our subgroup analyses showed no association between baseline SMBG frequency and outcomes.
Why, then, do so many payers continue to restrict CGM use only to individuals with T1D who test 4 times daily? Moreover, why is there such diversity among payers in their coverage policies? The answer may lie in the evidence used in their decisions and where they are getting it.
Payers often hire for-profit health research and technology organizations for guidance in coverage policy decisions. Their guidance is based on evidence gleaned from the literature. However, these organizations use varying methods for assessing the evidence used in their recommendations. For example, some may use the traditional model of five evidence levels, where systematic reviews and meta-analyses are deemed the highest level and RCTs are considered the second highest. Conversely, the ADA considers SRMAs and RCTs to carry equal weight in grading the evidence used in their clinical guidelines. It is our position that the ADA model should be adopted by all policy decision makers when developing guidance recommendations and coverage policies that impact individuals with diabetes.
Why Are My Insulin Pump/continuous Glucose Monitor Supplies So Expensive
There are two components of health insurance coverage: medical coverage and pharmacy coverage. Pharmacy covers prescription medications. Medical covers physician visits, tests, hospitalizations, and more, including a category called durable medical equipment .
CGMs, insulin pumps, and insulin pump supplies are considered DME, therefore they fall under the medical plan rather than the pharmacy plan .
Because they are billed through the medical channel, you must first meet your deductible and then pay your coinsurance on these supplies until you reach your out-of-pocket limit. This can be a prohibitively burdensome cost, particularly for those with high deductibles, but can remain prohibitive even once your deductible is hit.
What can you do?
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Cgm For Basal Insulin Users
Some research on using CGM for basal insulin users has found that it helps not only with monitoring blood sugar first thing in the morning but keeping tabs on what is happening overnight, which is important to know, Dr. Pettus says.
In one study, 65 people with type 2 were assigned to SMBG or CGM. Those on CGM reduced calorie intake, lost weight and doubled their exercise time. And the researchers found the AIC reductions in the CGM group persisted. “Can you imagine if that was a pill?” Dr. Pettus asks.3
In another study, researchers followed 26 people with type 2 diabetes given CGM, tracking them for six months. Their A1C declined, on average, from 8.9% to 7%. However, they also had great support from health care providers, Dr. Polonsky says. They could request a meeting with a diabetes educator for more education about how to use CGM and how to make lifestyle changes. So, he asks, was it the technology or the human support? More evidence is needed in this group, he says.4
Faq: Levels Cgm And The Diabetes Community
Answers to some common questions about Levels mission and process, and why were bringing CGM to a broader audience.
The Levels Team
As a company focused on solving the metabolic health crisis, Levels work intersects with the Type 1 and Type 2 diabetes communities. For the moment, we use some of the same toolsparticularly continuous glucose monitorsand frequently speak about glucose and insulin.
Because of this, weve heard some questions and concerns on social media about why we serve healthy people and whether our work affects people with diabetes. We want to be unequivocal in our support for the diabetes community and our commitment to promoting overall metabolic health in a way that does not harm the people who use this technology to manage their conditions.
Here we address some common misconceptions. If you have additional feedback or inquiries, please let us know on Twitter .
For additional perspective on Levels from people with Type 1 diabetes, here are two recent articles:
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Why Do People With Type 2 Diabetes Need A Cgm
The more blood sugar data you have, the more you can live safely day-to-day with diabetes and prevent the development or progression of diabetes complications.
While A1c testing offers a glimpse into how your blood sugars have been doing over the course of the previous three months, it cant help you in your day-to-day, hour-by-hour diabetes management.
An A1c result cannot tell you what times of day your blood sugars are frequently high or frequently low to help you make adjustments in your regimen and medicationswith support from your healthcare team.
Blood sugar checks using test-strips, a meter, and a finger-prick are also lacking because it doesnt tell you the direction of your blood sugar. Like an A1c result, it also cannot alert you to rising or falling levels while you are sleeping, walking your dog, or while you are driving.
A CGM, on the other hand, can tell you:
- Real-time blood sugar levels every 5 minutes
- Your average blood sugar
- Your time-in-range, above range, below range
- If your blood sugar is rapidly falling or rising
- If you fall low while you are asleep otherwise occupied
- When and how often you are high or low
- and share this data in real-time with a family member
- and share this data in reports with your healthcare team
Who Is Covered By Medicaid
Whereas Medicare is a federal program that is the same everywhere in the country, Medicaid varies from state to state. Medicaid provides coverage mainly to low-income adults, children, pregnant women, and some parents. In states that have expanded Medicaid under the Affordable Care Act , people can qualify for Medicaid if their income level is below 133% of the federal poverty level. In states without expansion, many people below the poverty line neither qualify for Medicaid nor are able to afford a subsidized private health plan through the Health Insurance Marketplace.
To find out if you qualify for Medicaid in your state, click here.
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Cgm Coverage If You Have Medicare
Over 62 million people are enrolled in Medicare in the US and about 30% of those people live with diabetes.
There are several criteria a person has to fulfill to be eligible for a CGM through Medicare, but a redundant barrier to coverage was removed recently which should make it easier to get coverage for CGM.
This barrier was removed at the beginning of July 18, 2021, where Medicare eliminated the four-time-daily fingerstick testing requirement for CGM coverage.
So if you have been denied coverage in the past because you didnt manually check your blood sugar four times daily, now is the time to re-apply for CGM coverage.
To be eligible for coverage through Medicare, you still have to fulfill these criteria:
- You must live with diabetes
- You have to manage your diabetes with multiple daily insulin injections or an insulin pump
- You must require frequent insulin self-adjustment based on the CGM or finger sticks
- You must have seen a medical professional in person within 6 months prior to ordering the CGM
- You must see the prescribing medical professional in person every 6 months following the initial prescription of the CGM
Your out-of-pocket cost for your CGM will depend on what your Medicare benefit plan looks like. But instead of spending hours on the phone trying to get through to a Medicare representative, another option is to just reach out to US MED and have them run the numbers for you.
Are There Benefits To Using A Cgm Device And An Insulin Pump
While both devices offer unique benefits, CGM systems and pumps that work together can offer additional benefits. Some pumps will make certain insulin delivery adjustments automatically based on data from a CGM. Even these joint systems still require user input and management but can offer an added level of safety and a quicker response to increasing and decreasing glucose levels.
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How Does Cgm Work
With CGM devices, patients, caregivers and healthcare providers can identify patterns in behavior, diet, and blood glucose levels that would otherwise be impossible to see. A CGM device operates via a small water resistant glucose sensor that is placed just below the surface of the skin and held in place with an adhesive patch. These sensors can be worn up to 14 days continuously, usually on the torso or upper arm, transmitting blood glucose levels to a reader every few minutes. Thats a lot of data! More information equals more efficient diabetes management. Continuous glucose monitoring systems have been shown to be better at helping people with Type 1 diabetes lower their HBA1C as compared to traditional self-monitoring.
It is much easier to predict and potentially head off hypoglycemia and hyperglycemia events when you can see where blood glucose levels are headed in advance. This is especially true for those with erratic blood glucose levels, hypoglycemic unawareness, children who cant self-monitor, and others.
What Do States That Cover Cgm Under Medicaid Have In Common
Medicaid expansion: All of the states that cover CGM for people with both type 1 and type 2 diabetes the states shown in green have also adopted Medicaid expansion.
Diabetes prevalence: While it might be expected that states with the highest diabetes prevalence would also have the greatest investment in diabetes tools, this does not seem to be the case. Among the sixteen states with at least twelve percent of adults with diabetes, only four states cover CGM under Medicaid for people with both type 1 and type 2 diabetes.
Medicaid spending: With the exception of IL and MA, states with the highest Medicaid spending typically do not cover CGM for people with both type 1 and type 2 diabetes. We speculate that this is because coverage for all people with diabetes requires purchasing all of the CGMs, and states may be wary of this high initial cost. However, this approach is not actually cost-effective because the cost of diabetes supplies, such as CGMs, account for only 1.1% of the total cost of diabetes, while the costs of treating complications and lost productivity both expenses that would be reduced with widespread CGM use account for 73.1% of total diabetes costs. Thus, CGMs should not be the focus of cost-cutting efforts.
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Is Dexcom Covered By Medicare
Does Medicare cover Dexcom G6?
Yes. The Dexcom G6 Continuous Glucose Monitoring System is covered by Medicare for patients who meet the Medicare coverage criteria. Medicare coverage for therapeutic CGM includes certain beneficiaries who have either type 1 or type 2 diabetes and intensively manage their insulin. Dexcom now ships Dexcom G6 to Medicare patients with traditional fee-for-service coverage. For a full description of coverage criteria, .
Medicare Coverage Criteria
Medicare patients with type 1 and type 2 diabetes on intensive insulin therapy may be able to obtain reimbursement if the following Medicare coverage criteria are met:
- The patient has diabetes
- The patient is insulin-treated with three or more daily administrations of insulin or a continuous subcutaneous insulin infusion pump
- The patient’s insulin treatment regimen requires frequent adjustments based on BGM or CGM testing results
- Within six months prior to ordering the CGM, the patient had an in-person visit with the treating practitioner to evaluate their diabetes control and determine that the above criteria have been met and
- Every six months following the initial prescription of the CGM, the patient has an in-person visit with the treating practitioner to assess adherence to their CGM regimen and diabetes treatment plan.
*To view a list of compatible smart devices, visit dexcom.com/compatibility
I am an existing Medicare customer. How do I get my ongoing Dexcom G6 supplies?
CMS Policy
Does My States Medicaid Program Cover Cgm
It depends. Even if CGM is covered under your states policy, each state has its own criteria for which individuals qualify to receive it. For example, some states only cover CGM for type 1 diabetes, and other states have differing policies for short-term and long-term CGM use. To find out more about your specific states policy, check out our map below:
This map is the general landscape of Medicaid coverage for CGM. The fifteen states shown in red offer no coverage of CGM for Medicaid recipients, while the rest of the states offer some degree of coverage, as shown in the legend.
Fourteen states Medicaid programs provide CGM for people with both type 1 and type 2 diabetes: Alaska, Connecticut, Idaho, Illinois, Iowa, Indiana, Maine, Massachusetts, Minnesota, New Mexico, Ohio, Virginia, Washington, and West Virginia.
Seventeen states Medicaid programs provide CGM for people with type 1 diabetes only: Kentucky, Louisiana, Maryland, Michigan, Mississippi, New Hampshire, New York, North Carolina, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Vermont, Wisconsin, and Wyoming.
Four states Medicaid programs provide CGM for children only: Alabama, California, Florida, and Georgia.
Keep in mind that the information covered here constitutes what is publicly available and is not necessarily comprehensive. To get a definitive answer about whether you are covered, please consult your healthcare provider or your insurance plan benefits document.
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