Dexcom G5 and Medicare:  What’s Going On?

Posted on by

History

On January 12, 2017, the Centers for Medicare & Medicaid Services (CMS) released a ruling indicating that the Dexcom G5 CGM was a therapeutic medical device and eligible for reimbursement as Durable Medical Equipment (DME). I published a blogpost on 1/15/17 discussing this ruling and I urge you to read it as background for what has been going on (or not going on) in the last six months.

On 6/1/17 Mike Hoskins of Diabetes Mine published an article titled “Stuck Waiting for Medicare CGM Access” and this is good background for connecting the dots from January to June. Yours truly (Laddie Lindahl in Minnesota!!!) was one of the seniors highlighted in the article. Mike summed up the last six months pretty well by writing:

“but so far CMS has not proposed a national coverage policy. As a result, many PWDs on Medicare who previously had coverage or are trying to get CGM coverage are being told they can’t get the devices and supplies they need because “nothing is finalized yet.”

I found the end of the Diabetes Mine article to be quite alarming as Mike suggested:

“Insurance companies send out their contracts to medical supply distributors during the summer months, leading up to open enrollment periods that typically start in the Fall months. So right now is a critical time. Contracts are being crafted and finalized, and with all this Medicare CGM confusion, insurers and third-party distributors may very well simply leave out any language about Dexcom G5 coverage. Effectively, Medicare CGM’ers could face no coverage for their Dexcom supplies for 2018 because so much is up in the air right now.”

I transitioned to Medicare in April anI have been able to continue using my Dexcom CGM due to an extra G4 transmitter saved from my free upgrade to the G5 and from a couple of boxes of stockpiled sensors. Everything I am using is out of warranty, but it works. I am okay….but only for a while. This spring it was announced that Liberty Medical was going to be the authorized Medicare supplier for the Dexcom G5. They were quickly overwhelmed by the demand. (Who knew that it was so complicated?) I placed an order with Liberty and canceled it within a few days of shipping. It had become common knowledge that Liberty was not being reimbursed by Medicare and those of us placing orders might be responsible for the out-of-pocket cost. Meanwhile Liberty withdrew from supplying G5 supplies under Medicare as of 5/28/17.

Where are We Now?

I have had no reliable information source during the last weeks and months, but I have managed to piece together some news. Here is some info with the source and I’ll let you judge the reliability.

Dexcom: Some people on Facebook have mentioned email updates from Dexcom and I have called the company several times and was assured that I was on “The List.” I’ve never received an email. Yesterday I called Dexcom and learned a few new things.

1) Dexcom has set up a Medicare link in their phone menu. Call the Customer Service number at 888-738-3646. Select Option #1 for placing an order. Within that menu, select Option #1 for Medicare Help. Please note that Dexcom is experiencing high call volume about Medicare and I waited almost 10 minutes on hold.

2) If you are desperately out of supplies, call Dexcom and in some cases they are providing supplies.

3) I suggest that you call Dexcom to ensure that your account has the correct insurance information. On Tuesday mine was showing private insurance and Edgepark as my supplier. It has now been corrected to show Medicare as my primary and BCBS as my supplemental.

4) I was told on Tuesday that we each have a “Reorder Specialist” assigned to our account. I found out the name of my specialist and got his contact information. I was told that these specialists are sending out the informational emails and I had not received any because I was not “in his pipeline.”

Facebook: I am in a Facebook group called Seniors with sensors (CGM’s) where members share their experiences and opinions. Of course a lot of the info is “my endo told me” or “the Dexcom email said” or “the letter from Liberty said.”  We all know that the world will collapse into a black hole when Facebook is the source of all knowledge, but here are some things that I have learned:

“I heard from my endo this morning that Dexcom will be doing their own distribution for their Medicare CGM products. No third party like Liberty Medical (thank god.) The hang up at the moment is they are looking for a supplier for meters/strips which Medicare is requiring.” 6/21/17

“Dexcom also told me this week that they will be distributors.” 6/21/17

“I just got off the phone with a very nice Dex Customer Service Rep. Still many unanswered questions from Medicare but she says they expect to be alerting those on the waiting list by end of June” (The rep I spoke with yesterday was unwilling to give me any timetable.) 6/19/17

‘Did you get the email today from Dex with updated requirements from Medicare? They are ” working on it .” Still no way we can use phone / watch combo. I think that ageist and unfair.” 6/15/17

Diabetes Mine: In a 6/15/17 article about the ADA Scientific Sessions, Mike Hoskins and Amy Tenderich shared an update from Dexcom executives:

“If you’re wondering what’s going on with Medicare coverage of Dexcom CGM, here’s the rub: CMS has mandated that Dexcom ship out to Medicare patients “everything they would need” to use the product. Since calibrations with a fingerstick meter are required, that means Dexcom has to find a traditional meter company to partner with to actually ship meters and test strips in the package with their CGM. Kinda crazy, and definitely creating delays for the company and its customers!”

The Part We Hate!

It is becoming increasingly clear that unless things change, Medicare users of the Dexcom G5 will be forbidden from using their smartphones in any form. I understand and previously wrote about the importance of the receiver in allowing the G5 to be designated as DME. The idea that one cannot use a smartphone in conjunction with the receiver is absurd. The dollar value of Medicare reimbursement is significant enough that I can go back to using my receiver, but I hate the idea of abandoning my phone and especially the ability to see my Dexcom numbers on my Apple Watch.

For me it is an inconvenience. But how about those seniors who benefit from someone using the Follow app to monitor their BG trends. How about those seniors who use the accessibility features of their iPhone to access their BG numbers?

It is a stupid requirement. At the same time, my personal feeling is that we need to establish Medicare CGM coverage before we fight this battle. If you read the original CMS ruling, the only reason that the Dexcom G5 qualifies as DME is because of the receiver. If we don’t need the receiver, then unfortunately the G5 is no longer DME. So we need to be careful. That is my 2 cents!!!

What Others Are Saying?

When I began writing this blogpost, I asked my fellow seniors from the Seniors with sensors (CGM’s) Facebook group to share their thoughts. I learned a lot.

“Although it will be a inconvenience for most of us, which will hopefully be temporary, those using the Tandem X2 insulin pump or an Apple Watch series 2 should still be able to connect directly to the Dexcom G5 via Bluetooth by this fall with expected software upgrades from both Apple and Tandem”  —Larry

My T1D husband has a traumatic brain injury. So it is invaluable to me, his 24/7 caregiver for 3 1/2 years to be able to use the share/follow app. He had a severe car accident due to a low blood sugar which the initial 4 months of hospitalizations and rehabilitation cost almost 2 million dollars. If he would have just had a CGM it would have saved all that money, he would still be working and not on disability, and I would still be working. Every diabetic at diagnosis should get a CGM and certainly should not get them taken away at medicare age. He got his after coming out of rehab. We as caregivers near and far need to be able to assist our diabetic family and friends with the features Dexcom has like Share and Follow. —Barry and Kim.

As a type one diabetic who lives alone, it is mandatory to have a CGM that is 100% covered by Medicare. This is a lifesaver. As much as I would hate to be without either my Tandem pump or my Dexcom CGM, my Dexcom is crucial to my daily survival. I will be eligible for Medicare in September, 2017, and I am so very disappointed to find that I will have fewer benefits than I do with private insurance now.  —Cindy

Laddie, my biggest concern is with the exclusion of phones, and especially smart watches from Medicare’s program. In my opinion the use of a Smartwatch to manage Bg and treat T1D is a major advance in T1D care. It is a real time process. No phone need come out of a pocket, no receiver from same or elsewhere. Tap your watch,see your Bg, make treatment decisions in real time. I have been absolutely amazed by this one simple process and the impact it’s had on my life and T1D management. Somehow we must get Medicare to recognize this and allow the use of this technology for treatment. Either that or Dexcom has to build a receiver/watch.  —Dave

I am a Therapist. The watch being important to my work. It is not possible for me to check my blood sugar on a receiver or even a phone at this point during office visits. This restriction on app use is going to cause a problem for me .  —Deidre

Two Medicare people in my household. Repeatedly denied CGM coverage despite multiple appeals and documented Certificates of Medical Necessity the app by my PCP/Endo. Brittle Type 1 46 years with history of severe hypos with seizures and one incident of Nocturnal hypoglycemia leading to coma. One incident of severe DKA requiring 5 days in ICU.  —John

I haven’t experienced a coma yet, but that’s what happens when you have no cgms or no partner to watch over you.  —Dianna

I know, Dianna. Before my CGM I was almost afraid to go to sleep at night.  —Cindy

Signed up for the CGM in January. Now middle of June. Still waiting. Yesterday, another low where I crawled to kitchen for OJ. Made it again. Every time, I wonder when the time will come when I don’t make it.  —Camille

Summary

I think that Camille said it all:  “Yesterday, another low where I crawled to kitchen for OJ. Made it again. Every time, I wonder when the time will come when I don’t make it.”

21 thoughts on “Dexcom G5 and Medicare:  What’s Going On?”

  1. I am wondering if Medicare plans to use receiver downloads as a means to prove the systems they are paying for, are being used. And, what meter and strips we will be obligated to use, with little or no concern for accuracy.

    • I think that it remains to be seen what things will be enforced when Medicare starts reimbursing the Dexcom G5. I expect that to start we will not use our smartphones. I do not expect that anyone will check whether I use the Medicare-provided meter. To all of us with diabetes using a CGM, this is a huge thing. To Medicare, our expenses are a tiny part of what is being reimbursed. a year from now, we will know a lot more. 😀

  2. Laddie, I agree with you that we need one good fight at a time. Medicare is being dumb about the whole thing, and it will drive up costs, but let’s say one thing at a time and getting coverage sorted out is our number one issue.

  3. Seems pretty simple for Dexcom to fix most of this problem by making the transmitter durable.
    They would have to make the cells replaceable like on a watch or else rechargeable to last 4 years.
    Then the receiver you use would become unimportant.

    • Absolutely right, John, but unfortunately that is not the direction that Dexcom is going. I listened to a podcast yesterday interviewing Kevin Sayer, the CEO of Dexcom. When asked about transmitter life, he confirmed the continuation of the 3-month life. I have 15 minutes left to listen to, so I don’t know whether Medicare will be addressed in the Podcast. http://www.ardensday.com/episodes/jbp116

  4. Hi Laddie, Thanks for the update info as we were very happy to have read your update blog!

    Yesterday, I wrote an email to Dexcom requesting a placeholder spot for my wife Nancy who needs this device desperately because of her unaware episodes of hypo-glycemia which BTW she had another episode last evening and averages ~3/week. If I wasn’t around to help her she would be in an ER for sure, or in a diabetic coma. Today, I received an email from the Dexcom Supervisor of new patient sales in San Diego for the Ohio Valley. He explained that we have to take the new BG meter they are providing, and yet another meter that she really does not need because her Omnipod PDM has a Free Style meter built-in and she tests at least 6 times/day. This is a Medicare requirement, or CMS will not pay for the Dex 5 unless the the complete “package” as described by Mr. Hoskins in his blog above is delivered. So we are waiting till the Dexcom team gets some more patient notes from my wife’s Endo then hopefully we should be good-to-go sometime in July. Thank You & Take Care!

    • I’m so glad that it looks as though your wife will get the much-needed Dexcom soon. I keep my fingers crossed that the selected meter will be a good one. I use Freestyle just as your wife does and it would be great if that is the chosen meter. But I’m not counting on it….

      • Laddie, Thank you for the kind words! This was the Dexcom’s sales manager’s reply to us ” The new BG meter will be a requirement to be shipped out. That is not our policy, that is Medicare’s requirement. We want to make sure that if we send this to you, that you are not held liable for the claim. When the time comes I can look into that exception, but to date our instruction is that Medicare is pretty black and white with their requirements – part of the reason that this is taking as long as it is.”
        From the sound of it, it looks like the BG meter may not be a Abbott-FreeStyle meter? Since I’m a disabled veteran, my wife gets her diabetic supplies through the VA, and the VA has a huge contract with Abbott for their freestyle test strips. I wondered why Medicare wouldn’t insist on this being the meter of choice since the VA and CMS are both under the US Government? No one negotiates medical contracts better than the VA with the Drug Companies as they get the most bang for their buck.

  5. I have been using Dexcom 5 at my own expense since September 2016. I have been attempting to get Medicare coverage through my Medicare Advantage Plan since February 2017. I have been in contact with Dexcom, Liberty Medical, and UnitedHealtcare too many times to count.Still have not received approval for coverage. Dexcom has been the most helpful in meeting my current needs.
    The process is unbelievable. I hope Dexcom gets approvals they need for test strips etc.

    • I am optimistic that the details will be worked out soon, but I’m not sure exactly what “soon” means. Some “oldtimers” have told me that this is how it originally was with insulin pump coverage by Medicare, so the delay is not unprecedented.

      Thanks so much for reading and commenting, Louis.

    • I am having a similar experience. Obtained approval from my United Healthcare Advantage Plan through Liberty. By the time approval was received Liberty was bought out by Edgepark. Edgepark informed me they would not supply me due to no contract with United. Dexcom offered the same turn down due to no contract. Dexcom referred me to ADS. They gave same reply. United Healthcare referred me to Byram Health Care. They seem to be willing to help. I am waiting for confirmation. In the mean time, Dexcom has furnished me 2 free sensors. Mostly paying out of pocket and have been for 2 years.

  6. This may not be a good device for Medicare patients. Dexcom says they are “in partnership” with Medicare but Medicare says they will cease providing the DexCom G5 for anyone who uses their smart phone with or without the Dexcom receiver. This means that Medicare is refusing to allow your significant other to receive low blood sugar warnings through the use of cell phones. Any other DexCom customer can use their smart phone to allow for automatic high or low blood sugar notices to be sent to loved ones.

    Personally, I think it is a mistake for Dexcom to be seen in partnership against the best medical interests of their own customers.

    I desperately need to have my spouse be informed if my blood sugar drops so low that I can’t respond. But I can’t have the DexCom iphone app on my phone that could alert my wife. To me, it’s only a matter of time until someone dies due to this insane Medicare ruling and DexCom’s acceptance of it. DexCom said a while back that some Medicare patient tried to get Medicare to give them a free iphone so this is how Medicare is mitigating against that possibility. But why not just say that iphone aren’t included instead of handling this the way they have?

    • We have to hope that the smartphone policy will be changed soon although I’m not sure that anything ever happens quickly with Medicare.

  7. Just found your blog I am a T1D and have been on Dexcom for over a year before Medicare said they will cover the G5. I am on tricare for life for the past 4 years and I findley got my call back from “My Dexcom Agent” so I can get my package. He also ask for a credit card to cover the “subscription service” ($49 and change) each month this is the first that I have heard this and I have not see anything in print about this. They said that this charge might not be covered by insturance. They are supposed to get back to me on what this is all about. He said it due to Medicare saying that they must set this up for a month at a time shipments. Have you heard anything about this from anyone?

    • If you normally have to pay 20% for your Durable Medical Equipment (DME), that $49 would be your 20% although Dexcom is calling it a subscription fee. I have Basic Medicare which will pay 80% of the cost and then my supplemental will pay the remaining 20%. Your cost, if any, will depend on how Tricare for Life covers your DME. Are you on a pump? If so, do you pay 20% for your pump supplies or are they paid for !00%. Chances are that the CGM will be covered exactly like your pump supplies.

  8. Hey! Dexcom will be supplying the Bayer Contour Next meters which is really surprising considering the only way people can get these meters is having to be on an insulin pump. These meters are the number 1 in accuracy by far. You guys can be happy about that.

    I work at the University of Washing Diabetes Care Center. This has been a mess but it looks like Dexcom and Medicare are getting somewhere. Slowly.

    • You’re right, David. It has been a mess but things are slowly being worked out.

      I was very pleased with the choice of the Contour Next meter. I really was expecting that they would provide us with junk meters and strips. I truly believe that the more accurate/consistent your meter is, the better Dexcom tracks.

      Thanks for reading.

  9. 9/18/2017 I have been trying for more than 6 weeks to get my wife enrolled in Dexcom’s Medicare plan. Many, many times we have been told that the only thing remaining is ‘proper’ response from the doctor’s office. From Cool Hand Luke decades ago — “What we have here is a failure to communicate.”
    Is anyone else having ‘communication’ problems, especially placing the blame on the doctor’s response?
    Cayce Warf
    cell: 425-985-7262
    caycewarf@comcast.net

    • Yes, I have others having a similar problem. Dexcom is overwhelmed with the volume of requests and slowly making progress supplying seniors with the Dexcom G5. I know one person whom last week Dexcom transferred to another supplier because Dexcom couldn’t keep up with the demand. Also I have read that the form the doctor’s office must complete must be done exactly right or that will case a delay. If you participate on Facebook, there is a group called Seniors with Sensors (CGMs) where many are sharing their experiences and you might find that to be a good source of information. It is a closed group but easy to join. https://www.facebook.com/groups/989708904400922/

Comments are closed.