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Where can Veterans Affairs patients fill their Dexcom G6 prescriptions?
Patients may be able to fill their Dexcom G6 supplies at the Veterans Affairs pharmacies.
What is the coverage criteria that can be used to see if a VA patient may be eligible for coverage?
To be eligible for Dexcom G6 coverage under Veterans Affairs, a healthcare provider must document that the patient meets the following qualifying criteria:*
- Has diabetes
- Performs frequent blood glucose monitoring (BGM) testing (≥4x/day)
- Takes ≥3 daily injections of insulin or uses an insulin pump or
- Has the skillset and knowledge to use CGM successfully
- Has agreed to be followed-up in the clinic a minimum of every six months
- And is one or more of the following:
- At risk for hypoglycemia
- Unable to meet glycemic control despite adherence to the treatment regimen
- Performing job-related activities where a hypoglycemic event could put them at risk of harm
- Unable to perform self-monitoring of blood glucose due to disability or disease
*For a complete description of Veterans Affairs coverage criteria and additional information, please see the Department of Veterans Affairs Criteria for Use Memorandum, January 31, 2019. A patient must be seen at a VA healthcare facility or a VA Community Care Network clinic to be eligible to receive coverage.
Disclaimer: CGM coverage and reimbursement information is being provided on an “as is” basis at the time of publication, with no express or implied warranty of any kind, and should be used solely for informational purposes. All coding, coverage policies, and reimbursement information are subject to change without notice. Coverage for CGM depends on a variety of factors, and coverage conditions will apply. Not all patients will be covered for Dexcom G6 or any other CGM device. Dexcom, Inc. does not represent or guarantee coverage under any applicable payor, program, or plan. The information provided herein does not constitute professional or legal advice on coverage or reimbursement and should be used at your sole liability and discretion. Dexcom, Inc. does not represent or warrant that any of the information being provided is true or correct and you agree to hold Dexcom, Inc. harmless in the event of any loss, damage, liability, expense, or claim arising from your use or reliance on this coverage or reimbursement information for billing purposes. Before submitting any claims for reimbursement to any payor, it is the provider’s sole responsibility to verify compliance with the payor’s current coverage conditions.
Last updated November 20,2020.
Is Dexcom G6 covered by Veterans Affairs benefits?
Yes, patients with type 1 or type 2 diabetes who meet the qualifying criteria* may be eligible for coverage of the Dexcom G6 Continuous Glucose Monitoring (CGM) System.
*For a complete description of Veterans Affairs coverage criteria and additional information, please see the Department of Veterans Affairs Criteria for Use Memorandum, January 31, 2019. A patient must be seen at a VA healthcare facility or a VA Community Care Network clinic to be eligible to receive coverage.
Disclaimer: CGM coverage and reimbursement information is being provided on an “as is” basis at the time of publication, with no express or implied warranty of any kind, and should be used solely for informational purposes. All coding, coverage policies, and reimbursement information are subject to change without notice. Coverage for CGM depends on a variety of factors, and coverage conditions will apply. Not all patients will be covered for Dexcom G6 or any other CGM device. Dexcom, Inc. does not represent or guarantee coverage under any applicable payor, program, or plan. The information provided herein does not constitute professional or legal advice on coverage or reimbursement and should be used at your sole liability and discretion. Dexcom, Inc. does not represent or warrant that any of the information being provided is true or correct and you agree to hold Dexcom, Inc. harmless in the event of any loss, damage, liability, expense, or claim arising from your use or reliance on this coverage or reimbursement information for billing purposes. Before submitting any claims for reimbursement to any payor, it is the provider’s sole responsibility to verify compliance with the payor’s current coverage conditions.
Last updated November 20,2020.
What should practices do if they get denied for CPT codes 95249 and 95250?
Claim denials can occur for a wide variety of reasons. It is important to understand why the claim was denied and as appropriate, know what options are available to resubmit or appeal the claim. Confirm that the ICD-10 diagnosis code(s) are specific and valid for services provided and that the specific codes and services of CPT codes 95249, 95250 and 95251 are covered services within each health plan.
Ensure that frequency of submissions is within the specific insurance policy limits. Modifier -25 should be added to Evaluation and Management code (E/M) if billed on the same day as CPT codes 95249, 95250 and 95251. Modifier -25 verifies that the E/M service was separate and identifiable from the CGM service. For insurance plans requiring prior authorization, ensure that the authorization has been obtained prior to the service being performed.
The Medicare fee schedules provided in the table are national averages. Where would healthcare providers find the local Medicare fee schedules for physicians in their state?
The Center for Medicare and Medicaid (CMS) has a website where you can find state and local fee schedules for all CPT codes: https://www.cms.gov/medicare/physician-fee-schedule/search/overview
What is the difference between the Medicare physician fee schedule and the outpatient diabetes center payment?
Medicare physician payments are fee schedules based on relative value units (RVUs). Hospital outpatient services are paid under the outpatient prospective payment system (OPPS).
Which insurance companies are paying for CPT codes 95249, 95250 and 95251? How do healthcare providers find out the specifics of each insurance company’s CGM coverage policy and criteria?
The majority of commercial insurance plans have written positive coverage decisions for both personal and professional use of CGM. National payers such as Cigna, Humana, Aetna, United Healthcare and Anthem WellPoint are currently covering these CPT codes, although the coverage criteria may differ between personal and professional use of CGM. Coverage decisions may vary and limit coverage to specific patients (i.e. type 1) or may limit number of times per year CPT codes 95249, 95250 and 95251 may be covered. Work with your health plans to get copies of the most recent published CGM coverage decisions. As always, verify coding and payment with your local payers.
If a patient has been using their Dexcom receiver and then switches to a compatible smart device† to display their glucose data, can the provider bill CPT code 95249 for this training?
It is highly unlikely any commercial payers would cover training costs for devices that are not reimbursed. (Medicare does not currently reimburse for a CGM system if a smart device is solely used to display glucose data. The patient must have a receiver to use in conjunction with the smart device.) However, providers should check with individual payers for specifics on billing when a patient switches to using a smart device for glucose data display.
If a patient starts using a Dexcom CGM System after previously using another manufacturer’s CGM system, can the HCP bill CPT code 95249 again?
Yes, the code can be billed again for commercially-insured and Medicare patients if the patient is using a different manufacturer’s CGM system or a different model of a data receiver from the manufacturer’s CGM system they are currently using.
Do services associated with CPT codes 95249 and 95250 need to be provided face-to-face?
Yes, all of the services associated with CPT codes 95249 and 95250 must be provided face-to-face in order to bill for them. Services associated with CPT code 95251, however, may be a non-face-to-face service.1
1 CPT 2019 Professional Edition. Chicago, IL: American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.