At the beginning of this year, the Centers for Medicare & Medicaid Services issued a new ruling, CMS-1682-R, dated January 12, 2017. This ruling has now defined a classification of: Therapeutic Continuous Glucose Monitors as “Durable Medical Equipment”. At this moment, the Dexcom G 5 continuous glucose monitor is the only therapeutic continuous glucose monitor. At the end of March 2017, my Dexcom G 4 has sensors and a transmitter out of warranty. My position is simple. I requested a Dexcom G 5 CGM. It was summarily denied. Why? The medical supplier utilized the standard billing codes for CGM components and Medicare deems the entire request as non-covered because of the billing codes. Really! What happened to a review of medical criteria for the service?
It is my position that Medicare has boxed itself into a corner. The time has come for Medicare to apply medical standards equally when compared to the non-Medicare population. Why should seniors have different medical criteria and codings when compared to our children and adult children when all are type 1 diabetics?
The starting point is the current Local Coverage Article: Glucose Monitor – Policy Article (A52464). The onerous line is on page 3 of 7.
“Continuous GLUCOSE MONITORs (A9276-A9278) is non-covered
Under the DME benefit.”
Also note on the beginning pages of Article (A52464) is the list of Contractor Information. The list defines regions of the country to specific contractors. One way to look at the contractors is that they serve as enforcers for Medicare delivery. Should Medicare Local Coverage Articles be promulgated by the contractors? How does Medicare and the Contractors determine their decisions? Are any of you aware of this group publishing the results of any clinical studies or reference any studies? Who is responsible for their decisions and what, if any is the process to request a reconsideration on the Local Coverage Articles? Why is the Medicare Appeal Process only an individual case-by-case determination?
The Department of Health and Human Services, Centers for Medicare & Medicaid Service issued a CMS Ruling. Ruling No.; [CMS-1682-R] dated January 12, 2017. For the Medicare Program, Medicare Supplement Medical Insurance (Part B) declared Classification of Therapeutic Continuous Glucose Monitors as “Durable Medical Equipment” under Medicare Part B.
The ruling was written with no consideration for implementation. What is covered, when is it covered, how is it covered and who is covered? The operative factor not addressed is the length of time needed to fully implement this ruling.
Medicare contractors have issued another article on March 23, 2017. An excellent review was written by Mary Caffrey for the American Journal of Managed Care, on March 28, 2017. This online review critics the restrictions that are destroying a coverage choice for Dexcom G 5 units via Medicare. There is another interesting Medicare document that can be brought into the picture for clarity concerning the implementation for the use of approved Dexcom G 5 CGMs Medicare does have a document which lists Durable medical equipment (DME) coverage.
It is obvious to me that there is no plan for implementation! Is it the ultimate goal of Medicare to enforce policies to remove and destroy the historically important doctor-patient relationships?
Recommendation for implementation from a Medicare senior and a type 1 diabetic for over fifty years.
- There is no reason to change the billing codes of (A9276-A9278) for the sensors, transmitters and receivers of a CGM. Dexcom included. The above referenced billing codes are applicable to children through adults through age 64 plus.
- There are multiple levels of contractual agreements between many parties involving coding coverage to aid in reimbursement for various parties. Why should private insurance organizations, medical supple companies, hospitals, pharmacies, and billing organization have different number codes for the same pieces of equipment? And be required to change them mid-year. There is a serious cost to implement a revised coding adjustment and could include training. Does anyone have any idea the time it takes to re-code billing documents for failure during a transition period mid-year without clear directions?
- Interesting facts: My first Dexcom unit was approved when I was 63 years young in December 2012-Janmuary 2013. The discussion was first between myself and my endocrinologist, prescription/orders were forwarded to a medical supply house which forwarded the request to my health care provider and was approved. If there was a question, it would have been a discussion between my endocrinologist and equal medical peers at the insurance company. It was approved. Who are the medical peers for Medicare and when, where and how do they enter the process? The uniform billing codes were employed. As required, my registration for Medicare was completed. Local coverage article (A472387) was in effect at the time. It took fourteen months and three levels of a CMS Appeals process for a successful approval and coverage of my Dexcom G 4 Platinum CGM.
- With a successful Medicare Appeal, my Medicare Advantage Plan was billed by a Medical supplier with the same codes, (A9276-A9278) as children and non-covered medicare adults. Conclusion: use the same billing codes for everyone.
- There is no reason to have a unique billing code just for Dexcom. What happens when future vendors and/or a newer improved therapeutic glucose monitor enters the market. Newer billing codes again!
- The Medicare ruling and the Local Coverage Articles are silent on integrated medical equipment. There are blood glucose monitors coordinated with an insulin pump. Next, there are insulin pumps which are coordinated with a Dexcom G 4 CGM. What is the decision for these groups of CGM users?
- Blood sugar monitors and blood sugar test strips are supplies defined as covered durable medical equipment (DME). Proposed rule change: add CGM sensors with billing code (A9276) as a supply item for blood sugar monitors. The CGM sensors are a type of sugar (glucose) sensor.
- Second Proposed rule change add the CGM transmitter, (A9277) and the CGM receiver, (A9278) as a supply item for insulin pumps. Conclusion: Is it the desire of Medicare to pay for the transition from insulin pumps with Dexcom G 4s to new pumps and Dexcom G 5 CGM units NOW, or wait until they become available. Recommendation: Cover the Dexcom G 4 components linked to an insulin pump and/or blood glucose meters with the opportunity to transition as quickly as possible. Such an action could stabilize the markets and present an option for new entries into Medicare.
- The successful transition to full utilization could take four years. This is based upon the fact that Medicare has ongoing new enrollees. Why should new enrollees have important diabetic medical equipment taken away? Especially, when approval had been granted prior to the new enrollee becoming Medicare eligible. The four year window is linked to the warranty period of prior approved pumps and other diabetic management equipment.
- Serious consideration needs to be given to drastically change the current Medical appeal process for Part A and B. How would you feel if a Medicare appeal which was started in 2012, and was not settled until December 2016 with a total of seven different hearings? This specific appeal was for approval of coverage for a Dexcom G 4 CGM.
- Will this person and all other prior successful recipients of approved Medicare coverage for Dexcom G 4 CGMs have the option to transition to the newly approved therapeutic Dexcom G 5? If not. Why not? They had previous been approved with coverage for all CGM components
- Final recommendation: Medicare should simply revise Local Coverage Article (A52464) to maximize coverage and minimize disruptions for a better transition approach to implement CMS-1682-R. This should also include a revision of the Durable medical Equipment (DME) coverage. I find it interesting to note that this document DOES NOT identify vendors directly. The earlier recommendations to the DME linkage will identify the diabetic equipment being employed by the patient and fulfill the positions established under CMS-1682-R.
In conclusion, it my concern and desire that medical standards are applied equally. There is no medical reason for Medicare to apply rules that make no sense medically given the fact that they exist in the non-medicare population. There is no logical reason or sense for the same medical insurance provider to approve a child with a Dexcom G 5 with smartphone technology for the necessary family members and then turn around and deny such coverage to Medicare seniors and their adult children. Why?
A society and culture can be judged by our concern and respect for the young and the old. It is time for Medicare to become responsive to Medicare patients. It is a waste of time, energy to tie up the delivery of medical services to arcane rules that can only be challenged though an arduous arcane appeals process which takes way to long. All non-Medicare type 1 diabetics need to be concerned. When coverage begins to slip for one part of the diabetic community the day will come when such rules will impact you and your diabetic care.