Medicare Certificate of Medical Necessity

Required documentation for prescribing CGM to Medicare patients

When prescribing a Dexcom CGM System to a Medicare patient, the Certificate of Medical Necessity is a required part of the document package for Medicare reimbursement. This form serves as the prescription and must be completed by the prescribing healthcare provider.

Medicare Certificate of Medical Necessity (pdf) 

Other documentation required for prescribing CGM to Medicare patients:

• Medicare Assignment of Benefits Form
• Images of insurance card(s) (front/back)
• Chart notes reflecting coverage criteria