The first case that successfully pushed back against the policy involved Wisconsin resident Jill Whitcomb, who has had Type 1 diabetes for 40 years. Ms. Whitcomb was first prescribed a CGM by a nurse practitioner, and she used it successfully during a six-month trial. In 2011, she sought to have the device covered under her UnitedHealthcare Securehorizons Medicare plan. The Medicare-insuring contractor denied the claim.
On April 29, 2016, an administrative law judge in the Medicare Civil Remedies Division ruling on a similar case invalidated an insurance benefit exclusion – again, the insuror had tried to argue that CGMs were precautionary equipment. The order again took insurors to task for failing to use scientific data to back up this argument.
“The contractor and CMS [Center for Medicare Services] 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 a CGM is never reasonable and necessary irrespective of the beneficiary’s condition,” the judge wrote.
In this case, the judge had reviewed all of Medicare’s requirements for coverage and determined that CGMs in fact meet the coverage requirements, said Parrish. In a practical sense, then, wider acceptance of CGMs by practitioners, patients, and private insurors is forcing the Medicare program and Medicare insurors to revisit their justifications for denying the benefit, she said. Approximately 95 percent of commercial insurors cover CGMs, according to an article appearing in American Journal of Managed Care.