Benefit Trends

CMS Announces a New Benefit Category for “Therapeutic” CGM

In 2017, the Centers for Medicare and Medicaid Services (CMS) Medicare made a milestone Ruling, establishing benefit coverage for “therapeutic” continuous glucose monitoring (CGM)—a designation applying only to those CGM systems approved for use in making diabetes treatment decisions without a fingerstick (“non-adjunctive use”). The Dexcom G5® CGM System is the only therapeutic CGM system covered by Medicare.

Note: The beneficiary may NOT use their phone either as a primary receiver or, as a secondary device and still be eligible for Therapeutic CGM.

Dexcom G5 Qualifies for Medicare Reimbursement as the First “Therapeutic CGM” on the Market

A link to the full CMS Ruling No. CMS-1682-R can be found here.

Details

Germany’s Ministry of Health Updates Reimbursement Policy to Include Continuous Glucose Monitoring (CGM) Systems

The Institute for Quality and Efficiency in Health Care (IQWiG) began their CGM treatment method assessment in 2011 and concluded that patients with insulin-dependent diabetes can better control their HbA1c value without serious hypoglycemia with CGM.1 This assessment and outcomes led Germany’s Ministry of Health to update its reimbursement policy to include Continuous Glucose Monitoring System (CGM) in September 2016, putting the technology in the hands of many who could not previously afford it.

The new reimbursement policy in Germany only covers technologies that provide alarms and alerts about glucose levels. Germany is the single largest market in Europe for Type 1 and Type 2 diabetes, with nearly 6.6 million people living with the disease, according to the International Diabetes Federation.

The Dexcom G5® Mobile CGM System and Dexcom G4® PLATINUM will be Included among the CGM devices that will be reimbursed by Germany's Medical Department of the Central Federal Association of Health Insurance Funds.

Leading Payer Strategies to Improve CGM Patient Access

The Opportunity

  • Removal of BG log requirements

The Rationale

  • During the onset of hypoglycemic symptoms, patients seek immediate treatment without always confirming the low on a blood glucose (BG) meter
  • Generally only one of multiple meters used are downloaded
  • The average individual with type 1 diabetes experiences about two episodes of symptomatic hypoglycemia per week2

The Opportunity

  • Removal of prior authorizations

The Rationale

  • Prior authorizations add to the administrative and workflow burden incurred by all parties
  • An authorization is largely a manual process which is time-consuming and expensive costing payer organizations as much as $340 PMPY3
  • Consensus statements from endocrine leaders point to the many benefits with AACE calling for wider use of CGM in diabetes treatment, because it improves outcomes by reducing hypoglycemia4

 

Dexcom is Helping Lower CGM Access Barriers

  • Dexcom has contracts/contracted with the Top 4 PBMs in the country5
  • Coverage of CGM for type 1 diabetes is offered for 98% of commercially insured members, and many plans also provide coverage for members with insulin-using type 2 diabetes.5
  • 20 million patients with type 2 diabetes have access to Dexcom CGM6
  • 23 states have an official CGM Medicaid coverage policy. An additional 9 states have limited access to Pediatrics <21 through the EPSDT program7
  • The only CGM solution with Medicare Part B reimbursement8
1

Institute for Quality and Efficiency in Health Care. Continuous Glucose Monitoring with Real-Time Measurement Devices Has Added Benefit. May 21, 2015.

2

McCrimmon RJ, Sherwin RS. Hypoglycemia in Type 1 Diabetes. Diabetes. 2010;59(10):2333-2339. doi:10.2337/db10-0103.

3

Am Health Drug Benefits. 2011 Jul-Aug; 4(4):233-235.

4

Fonseca V, Grunberger G, Anhalt H et al. CONTINUOUS GLUCOSE MONITORING: A CONSENSUS CONFERENCE OF THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY. Endocr Pract. 2016;22(8):1008-1021.

5

Decision Resource Guide, 2016.

6

Atlantic Information Services, Inc. Directory, 2015.

7

Dexcom internal data on file, 2017.

8

A link to the full CMS Ruling No. CMS-1682-R can be found at www.cms.gov/Regulations-and-Guidance/Guidance/Rulings/Downloads/CMS1682R.pdf.