Steps for Obtaining Case-By-Case Coverage For Continuous Glucose Monitors (CGM) In The Medicare Program
The Medicare program does not cover CGM. However, you may still be able to obtain coverage for yourself by submitting a claim and appealing Medicare's decision. To initiate this process, you must submit your CGM claim and receive the denial. Once Medicare denies your claim, you will need to go through each level of the Medicare appeals process, stopping only if your appeal is successful.
Remember, be prepared and persistent. The Medicare appeals process can be difficult and time consuming; however if you are persistent and take action at every phase of the appeals process, you may receive coverage for your CGM from Medicare. Make sure to be prepared and to keep trying!
There are five levels in the Medicare appeals process: Once an initial claim determination is made, beneficiaries, providers, and suppliers have the right to appeal Medicare coverage and payment decisions. Each stage of the appeals process is highlighted below. Please make sure to click on the hyperlinks to see the specific details for that Level of Appeal, including what information to include in your appeal. Your physician may be a good resource for developing the relevant information required for this process.
First Level of Appeal: You have 120 days from the date you receive the initial claim determination (the denial) to file an appeal, and you must request a redetermination of your claim in writing.
Second Level of Appeal: You must request a Second Level reconsideration in writing with a Qualified Independent Contractor (QIC) within 180 days of receipt of the redetermination from the First Level appeal. To request a Second Level reconsideration, follow the instructions on the Medicare Redetermination Notice (MRN) that you were sent after your first level of appeal or make a request using the standard form CMS-20033.
Third Level of Appeal: If at least $120 remains in controversy following the QIC's decision, you may request an Administrative Law Judge (ALJ) hearing within 60 days of receipt of that reconsideration decision. Refer to the reconsideration decision letter from the QIC for details regarding the procedures for requesting an ALJ hearing. In addition, you may use standard form CMS-20034 A/B to file a request for an ALJ hearing.
Fourth Level of Appeal: If you are dissatisfied with the ALJ's decision, you may request a review by the Medicare Appeals Council. You must submit your request for Medicare Appeals Council review in writing within 60 days of receipt of the ALJ's decision, and you must specify the issues and findings you are contesting.
Fifth Level of Appeal: If $1,180 or more is still in controversy following the Medicare Appeals Council's decision, you may request judicial review before a Federal District Court judge. You must request a Federal District Court hearing within 60 days of receipt of the Medicare Appeals Council's decision.