Decoding Dexcom G7 Medicare Coverage: A Lifeline for Diabetics

Living with type 1 or type 2 diabetes requires diligent monitoring and management, and technological advancements have significantly eased this burden for many. Since the FDA approved the Dexcom G7 in December 2022, many of you may be wondering whether you’re eligible for one and whether there is any Dexcom G7 Medicare coverage.

First, what’s so exciting about the Dexcom G7 anyway?

The Dexcom G6 was one of the most accurate and popular type of Continuous Glucose Monitor (CGM) device on the market. Using a CGM drastically reduces the need for fingersticks. It provides real-time data to help people diagnosed with diabetes, their loved ones, and healthcare providers make informed decisions about their health.

You can get glucose readings from the Dexcom receiver or a connected Dexcom app on your Smartphone, Smartwatch, or special watches like the Bluejay GTS. The device helps you monitor your glucose levels and anticipate trends, helping you make informed choices regarding food and physical activity.

The approach makes diabetes management so much easier. The Dexcom G6 was one of the best tools out there, leading to plenty of excitement for the Dexcom G7. The G7 promises to do all the same things, but with newer tech and hopefully better – leading to much anticipation.

In this article, we’ll provide a comprehensive overview of:

• Dexcom G7 Medicare coverage
• Requirements and eligibility
• Restrictions
• Steps to seek coverage
• Projected out-of-pocket expenditures

Dexcom G7 Medicare Coverage

Is Dexcom G7 Covered by Medicare?

First, Medicare does cover CGM systems like Dexcom, but only under certain conditions. You will need to meet particular requirements associated with your diabetes diagnosis and treatment plan.

General Requirements

As of April 2023, you are eligible for Medicare coverage for therapeutic CGM if you meet any of the general criteria:

• Have been diagnosed with type 1 diabetes, type 2 diabetes, or gestational diabetes
• Use insulin (in any form)
• Do not use insulin, but have experienced serious episodes of low blood glucose

Diabetes-Based Requirements

You may be surprised to learn that having diabetes alone doesn’t guarantee a prescription or Medicare coverage. Your provider will need to verify that your diabetes meets the following conditions.

• Use of any insulin for treatment
• History of problematic hypoglycemia, supported by documentation of:
  • One or more Level 2 hypoglycemic incidents (glucose <54mg/dL), despite adjustments made to treatment plan or medication, OR
  • One Level 3 hypoglycemic incident (glucose <54mg/dL) involving altered mental or physical state requiring assistance from a third party for hypoglycemia treatment.

How are lows documented? These could be reported by you, a caregiver, or documented with episodes requiring intervention from a third party, including emergency personnel. Some providers have offered Dexcoms on a temporary basis to test whether a patient is experiencing wild swings, including troublesome lows that fall into the ranges in Level 2 or 3 hypoglycemia.

Requirements Surrounding Education and Maintenance

Before granting you the Dexcom prescription, your physician will need to confirm that you and/or your caregiver understand how to use CGM. You will be asked to make an appointment with a diabetes educator in their office.

That’s always a good idea anyway.

From my experience, the G7 has its own quirks and having a sit-down with an educator can help boost your confidence with setting it up, especially when used with an insulin pump, applying it, and using the updated app.

Your provider will also need to verify that the CGM prescription adheres to FDA guidelines for its intended use.

Thereafter, to keep your CGM prescription active, you’ll need to check in with your provider on a regular basis.

• You have an in-person or Medicare-approved visit with the practitioner prescribing the CGM within six months after beginning CGM therapy.
• You have an in-person or Medicare-approved appointment with the practitioner who prescribed the CGM every six months after starting CGM therapy.

Dexcom Receiver Requirement

Not many people are fans of Dexcom’s receiver, as most opt for the Smartphone app. Still, in order to meet Medicare’s requirements for coverage of your Dexcom supplies, you must be willing to accept the receiver that comes with your Dexcom. This is true even if you intend to use a compatible smart device instead of the receiver.

The receiver constitutes the ‘durable’ in Durable Medical Equipment (DME), the categorization used by Medicare to make the cost eligible under Medicare Part B.

Now, whether you decide to stuff that receiver in a drawer is entirely up to you. It’s likely that Medicare also doesn’t want to be in the business of covering people’s cellphones, who want to claim them as a medical device.

Steps for Seeking Approval from Medicare

Beneficiaries should take the following steps to get approval for their upgrade to the Dexcom G7 or initial approval if this is their first time using this CGM.

1. Make an appointment with your primary care provider or endocrinologist.
2. Verify that your medical records clearly show that you have a diagnosis of Type 1 or Type 2 diabetes.
3. Confirm that your provider’s chart notes validate your compliance with the outlined criteria.
4. Healthcare professionals should submit the patient’s Certificate of Medical Necessity (CMN) and chart notes to distributors. The Certificate of Medical Necessity is mandatory for prescribing CGM to Medicare patients and is completed by the prescribing healthcare provider.
5. Ensure the completion of additional documents required for prescribing CGM to Medicare beneficiaries including:
   • Completed Medicare Assignment of Benefits Form
   • Copies of insurance card(s), including front and back
   • Chart notes showing fulfillment of coverage criteria
6. Once approved, the provider will send the prescription to the diabetes supplies distributor. Your healthcare providers should inform you that the distributor will contact you regarding your Dexcom G7 order. We get ours at our local pharmacy, but you can certainly opt for mail-order through a diabetes supplies distributor.

Anticipated Out-of-Pocket Expenses

Even when fully eligible for Medicare coverage of your Dexcom, you should anticipate some out-of-pocket expenses. Individuals should be ready to cover deductibles, coinsurance, or copayments based on their specific plan. Beneficiaries should know the potential costs they might incur before acquiring a CGM system.

Typically, Medicare patients are responsible for a 20% out-of-pocket contribution. However, if you have secondary coverage like Medigap or a Medicare Advantage Care plan, they generally handle your out-of-pocket expenses. Those covered by commercial insurance expenses will vary depending on your insurance plan.

If you are a Medicare beneficiary and do not meet any of the specified eligibility criteria for Dexcom G7 coverage, you may be stuck bearing the cost of the CGM yourself. 

If you are without CGM coverage, we encourage you to leverage the Dexcom Pharmacy Savings program, which enables savings of over $200 per month on Dexcom G7. For further details, visit the Dexcom Savings Center.

Upgrading from the Dexcom G6 to Dexcom G7

If you are already on the Dexcom G6 and wish to upgrade to the Dexcom G7, the speed at which that can happen will depend on a few factors.

Medicare only covers a new receiver every five years. If you’ve had the G6 for five years or longer, you should be able to upgrade immediately. Otherwise, you’ll need to wait until your fifth year.

Even if you’ve had the G6 for five years or longer, if you’re on an insulin pump, you’ll need to wait to upgrade to the G7 only once your pump manufacturer has confirmed they have fully integrated with your pump of choice.

• Insulet’s Tandem t:slim X2 Control IQ was the first pump to be integrated with the G7 in December 2023. You can read about my experience upgrading my daughter to the t:slim- Dexcom G7 combo from the G6.
• The Omnipod 5 System is not fully integrated with the Dexcom G7 for automated insulin delivery. You can, however, use it in manual mode.
• Check with your insulin pump’s manufacturer regularly to get updates on their integration status.

Conclusion

The Dexcom G7 is a powerful way to monitor your glucose levels and manage your diabetes effectively. It can also be helpful for caregivers, by making it easier to track when their loved one’s blood sugar isn’t in the right range.

However, it’s important to learn the technology well and pay attention to your instincts. We’ve certainly had times where the CGM’s read was off by a significant amount. So, if you’re not feeling quite right, it’s worth checking your levels with a finger prick, just to be sure.