Part B continuous glucose monitors (CGM) Form

2026 Medicare Part B Continuous Glucose Monitors

Preferred Continuous Glucose Monitors
• The below list of preferred continuous glucose monitors (CGM) is available for members that meet standard requirements for coverage, such as prior authorization and quantity limit restrictions.
• Coverage for a preferred CGM product is subject to the prior authorization criteria based on LCD L338221.
• Coverage for quantities that exceed the standard quantity limit is subject to the Quantity Limit Exception Criteria3.

Preferred CGM Products
Quantity Limits
Dexcom G6 Receiver
1 / 365 Days
Dexcom G6 Sensor
4 / 28 Days
Dexcom G6 Transmitter
1 / 90 Days
Dexcom G7 15 Day Sensor
2 / 30 Days
Dexcom G7 Receiver
1 / 365 Days
Dexcom G7 Sensor
3 / 30 Days
Freestyle Libre 14 Day Reader
1 / 365 Days
Freestyle Libre 14 Day Sensor
2 / 28 Days
Freestyle Libre 2 Plus Sensor
2 / 30 Days
Freestyle Libre 2 Reader
1 / 365 Days
Freestyle Libre 2 Sensor
2 / 28 Days
Freestyle Libre 3 Plus Sensor
2 / 30 Days
Freestyle Libre 3 Reader
1 / 365 Days
Freestyle Libre 3 Sensor
2 / 28 Days
Freestyle Libre Reader
1 / 365 Days

Non-Preferred Continuous Glucose Monitors
• The below list of non-preferred continuous glucose monitors (CGM) may be available for members if certain coverage requirements are met, such as step therapy and quantity limit restrictions.
• Coverage for a non-preferred CGM product is subject to the Non-Preferred CGM Step Therapy Criteria2. Step therapy requires trial of preferred products to treat a medical condition before covering a non-preferred product.
• Coverage for quantities that exceed the standard quantity limit is subject to the Quantity Limit Exception Criteria3.

Non-Preferred CGM Products
Quantity Limits
Enlite Glucose Sensor
5 / 30 Days
Eversense 365 Sensor/Holder
1 / 365 Days
Eversense 365 Smart Transmit
1 / 365 Days
Eversense E3 Sensor/Holder
1 / 180 Days
Eversense E3 Smart Transmitter
1 / 365 Days
Eversense Sensor/Holder
1 / 90 Days
Eversense Smart Transmitter
1 / 365 Days
Guardian 4 Glucose Sensor
4 / 28 Days
Guardian 4 Transmitter
1 / 365 Days
Guardian Connect Transmitter
1 / 365 Days
Guardian Link 3 Transmitter
1 / 365 Days
Guardian Real-Time Replace Ped
1 / 365 Days
Guardian Sensor 3
4 / 28 Days
Minilink Real-Time Transmitter
1 / 365 Days
Minimed 630g Guardian Press
1 / 365 Days
Minimed Instinct Gluc Sensor
2 / 30 Days Paradigm Real-Time Transmitter
1 / 365 Days
Simplera Sensor
4 / 28 Days
Simplera Sync Sensor
4 / 28 Days Simplera System
4 / 28 Days

References

1. Local Coverage Determination (LCD) L33822 – Glucose Monitors. https://www.cms.gov/medicarecoverage-database/view/lcd.aspx?lcdid=33822
2. Medicare Non-Preferred Continuous Glucose Monitors (CGM) Step Criteria
3. Medicare Continuous Glucose Monitors (CGM) Quantity Limit Exception Criteria