Prediabetes is a critical warning sign—a state where blood sugar levels are higher than normal but not high enough for a diabetes diagnosis. If left unmanaged, prediabetes can progress to Type 2 diabetes, increasing the risk of heart disease, nerve damage, and other serious health complications. Many people with prediabetes seek better ways to track their glucose levels in real-time, and one of the best tools for this is a Continuous Glucose Monitor (CGM).
A CGM helps individuals monitor blood sugar fluctuations throughout the day, providing instant feedback on how diet, exercise, and lifestyle choices affect glucose levels. But here’s the big question: does insurance cover CGM for prediabetes?
The short answer? In most cases, no. Health insurance providers often restrict CGM coverage to individuals with Type 1 or Type 2 diabetes, making it difficult for those with prediabetes to qualify. However, there are exceptions, and there are ways to access CGMs even if your insurance does not cover them.
In this article, we will uncover three shocking facts about insurance coverage for CGMs in prediabetes and explore strategies to help you navigate the system. If you’re trying to get a CGM to take control of your health, keep reading!
Fact #1: Most Insurance Plans Do Not Cover CGMs for Prediabetes
The harsh reality is that most insurance companies do not cover CGMs for prediabetes. Insurers often require a formal Type 1 or insulin-dependent Type 2 diabetes diagnosis to approve CGM coverage. This is because CGMs are considered medical necessity devices for individuals managing severe blood sugar fluctuations, especially those who use insulin or are at risk for hypoglycemia.
Why is CGM Coverage Restricted for Prediabetes?
Insurance companies make coverage decisions based on medical necessity, and they generally argue that prediabetes can be managed through:
- A1C blood tests (which provide an average blood sugar reading over three months)
- Periodic fingerstick glucose testing
- Lifestyle changes, such as dietary modifications and increased physical activity
Since prediabetes is considered a reversible condition, insurance providers may deny CGM coverage, stating that individuals can manage their glucose levels without a continuous tracking device.
Are There Any Exceptions?
While full CGM coverage for prediabetes is uncommon, some individuals can still get insurance approval if they meet certain conditions. Possible exceptions include:
- A doctor’s strong recommendation stating that a CGM is essential for preventing progression to diabetes
- Documented episodes of hypoglycemia (low blood sugar), which can be dangerous even in prediabetes
- Employer-sponsored insurance plans with broader coverage options
- Participation in a diabetes prevention program that includes CGM access
If you’re determined to get a CGM and believe it’s necessary for your health, talk to your doctor about potential workarounds. They may be able to help you make a case for medical necessity when discussing coverage with your insurance provider.
Fact #2: Partial Coverage and Reimbursement Options May Be Available
Even if your insurance does not fully cover a CGM for prediabetes, there are still ways to reduce the cost or get partial reimbursement.
Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA)
If your employer offers an HSA or FSA, you may be able to use these pre-tax funds to purchase a CGM. Since CGMs are considered medical devices, they often qualify for reimbursement under these plans. This can significantly reduce out-of-pocket costs.
Diabetes Prevention Programs (DPPs)
Some diabetes prevention programs offer CGMs as part of their initiatives. These programs, often run by hospitals, clinics, or insurance providers, focus on preventing Type 2 diabetes through lifestyle changes. Some include CGM access for participants who are at higher risk of developing diabetes.
Appealing a Denied Insurance Claim
If your insurance denies CGM coverage, you have the right to appeal the decision. Here’s how:
- Obtain a letter from your doctor stating why a CGM is medically necessary for your prediabetes management.
- Provide evidence of abnormal blood sugar fluctuations or risk factors that put you at a higher risk for developing diabetes.
- Ask your insurance provider for a policy breakdown and look for any exceptions or alternative coverage options.
- Submit a formal appeal to your insurance company, including all supporting documents from your doctor.
Although appealing a denial does not guarantee approval, some individuals have successfully secured partial or full CGM coverage by proving medical necessity.
Fact #3: CGMs Can Be Affordable Without Insurance
If insurance won’t cover a CGM, you may assume it’s too expensive to buy out-of-pocket. However, many people are surprised to learn that CGMs are more affordable than expected, especially with the right discounts.
How Much Does a CGM Cost Without Insurance?
The price of a CGM varies depending on the brand and model. Here’s a rough estimate of costs:
- FreeStyle Libre: You’ll pay $60-$100 per sensor (lasting 14 days). A one-time purchase of the reader will add approximately $50-$70. Bulk purchases or discounts may be available, potentially lowering the overall cost.
- Dexcom G6: The monthly cost for sensors and transmitters frequently exceeds $300-$400. This figure is based on typical usage and pricing; individual costs may vary slightly.
- Medtronic Guardian Connect: Expect monthly costs to regularly surpass $500 due to sensor and transmitter replacement expenses. This is a typical cost; individual expenses may differ.
While these costs add up, there are ways to save.
Ways to Reduce the Cost of a CGM
- Manufacturer Discount Programs
- Many CGM companies offer savings programs for individuals without insurance coverage.
- Check manufacturer websites for rebates, free trials, or discount cards.
- Buying in Bulk or Subscription Plans
- Some CGM manufacturers offer subscription discounts for individuals who commit to long-term use.
- Purchasing multiple sensors at once may also lower the overall cost.
- Clinical Trials & Research Studies
- Universities and medical research institutions sometimes provide free CGMs to participants in diabetes prevention studies.
- Check ClinicalTrials.gov to see if there are any studies in your area offering CGMs.
Final Thoughts
A continuous glucose monitor (CGM) can be a valuable tool for individuals with prediabetes, helping track blood sugar levels in real-time and prevent progression to Type 2 diabetes. However, most insurance plans do not cover CGMs for prediabetes, as they prioritize coverage for individuals with Type 1 or insulin-dependent Type 2 diabetes. Despite this, there are alternative ways to access a CGM, such as HSAs, FSAs, discount programs, and diabetes prevention initiatives.
If insurance won’t cover your CGM, consider exploring out-of-pocket options, manufacturer discounts, or pharmacy savings programs to reduce costs. Some individuals have also had success appealing denied claims with strong medical documentation from their doctors. While insurance limitations can be frustrating, investing in a CGM—even without full coverage—can be a game-changer for managing prediabetes and improving long-term health.
How Aptiva Medical Can Help You
Managing prediabetes can be challenging, but Aptiva Medical is here to help you gain better control over your health with Continuous Glucose Monitoring (CGM). Our team works with you to navigate insurance options, determine eligibility, and explore alternative ways to access a CGM device—even if insurance coverage is limited. With real-time glucose tracking, you can make informed decisions about diet, exercise, and lifestyle, helping you prevent the progression to Type 2 diabetes.
At Aptiva Medical, we believe that everyone deserves access to the latest tools for managing their health. Whether you need assistance with insurance claims, manufacturer discounts, or finding the right CGM for your needs, our experts are ready to guide you every step of the way. Don’t wait until diabetes develops—take control today with the support of Aptiva Medical and start monitoring your glucose levels with confidence!
