Judge Strikes Medicare Policy that Denied CGM as Precautionary

In December 2014, a Medicare beneficiary suffering from Type 1 diabetes filed a challenge against a Medicare policy asserting a continuous glucose monitor (“CGM”) is precautionary and therefore not covered by Medicare. The policy had been used to deny Medicare coverage of CGM for numerous Medicare beneficiaries despite the national and international recognition that CGM is the standard of care for certain individuals with diabetes. On April 29, 2016, a judge in Medicare’s Civil Remedies Division struck down the policy that CGMs are precautionary and therefore not durable medical equipment (“DME”) eligible for coverage under Medicare. The judge noted:

“The contractor [NHIC] and CMS have not produced any record in the form of peer-reviewed literature, medical opinions, or even an analysis from an individual with a medical background that supports a conclusion that CGM is never reasonable and necessary irrespective of the beneficiary’s condition. . . There is simply no evidence before me that explains how CGM does not meet DME requirements or why CGM cannot ever be reasonable and necessary under [the Medicare Act].”

Accordingly, the judge found that the policy statement that CGM is precautionary and therefore not covered under Medicare’s DME benefit to be invalid under the reasonableness standard. The judge reviewed each of the statutory elements for DME and how CGM satisfied those elements. Neither the Medicare contractor nor CMS submitted a single document or proposed a single witness in support of the position that CGM is precautionary.

The decision must be implemented within 30 days unless the Secretary of Health files an appeal within that time. Although the challenge was filed in a single DME Medicare jurisdiction, because all four Medicare DME contractors must have the same policies and articles, the ruling will cross all DME jurisdictions. The ruling should remove a significant obstacle for Medicare beneficiaries seeking Medicare coverage of CGM and supplies. Nonetheless, Medicare beneficiaries will still need to prove their need for CGM when seeking Medicare coverage. Even before the policy was stricken, a number of Medicare beneficiaries were able secure Medicare coverage of their CGM and supplies through the Medicare appeals process based on their demonstrated need. Read a copy of the decision here. 110966_C-15-1021 DECISION_20160429194039

Parrish Law Offices represented the Medicare beneficiary in the successful challenge. For additional information regarding the ruling, contact Bridget@dparrishlaw.com or Debbie@dparrishlaw.com.

Previous post:

Next post: