Last reviewed August 20, 2026 by the Medically Modern coverage team. This page explains payer rules. It is not medical advice — whether a CGM is right for you is a conversation with your doctor.
Clinically, you qualify for a Dexcom G7® if your doctor decides one is appropriate and writes a prescription. The G7 and G7 15 Day are prescription-only in the US regardless of how you pay. The harder question is whether your insurance will cover it, and that turns on a fairly consistent test across payers.
The test, in one box
You have diabetes mellitus, and either you are treated with insulin, or you have a documented history of problematic hypoglycemia. Plus a recent visit with the prescriber who orders it.
Medicare applies this test formally. Most commercial plans apply something close to it. Medicaid programs vary but tend to borrow the same structure. So it is a reasonable place to start no matter who your payer is.
Step 1: Do you use insulin?
If yes, you almost certainly meet the clinical branch. Since Medicare's 2023 expansion there is no longer any requirement to inject a certain number of times a day or test your blood sugar four times daily — any insulin, any regimen satisfies it. Dexcom reports about 87% of people using insulin have coverage.
If no, keep going — there is a second route.
Step 2: Do you have documented problematic hypoglycemia?
This is the branch for people who do not use insulin. Medicare's definition is specific, and commercial plans often mirror it. You need documentation of at least one of:
- Recurrent (more than one) level 2 hypoglycemic events — glucose below 54 mg/dL — that persist despite multiple attempts to adjust medication and/or modify your diabetes treatment plan.
- One level 3 hypoglycemic event — glucose below 54 mg/dL — with altered mental and/or physical state requiring third-party assistance to treat.
“Documented” is doing real work in that sentence. Lows you remember but that never made it into a chart note will not satisfy a payer. If you have been having them, tell your doctor specifically and ask that the readings and circumstances be recorded — that record is what a coverage decision rests on.
Step 3: Have you seen your prescriber recently?
This is the requirement people overlook, and on Medicare it is the most common reason a claim fails.
- Before the order: Medicare requires an in-person or approved telehealth visit with your treating practitioner within the six months prior to ordering, evaluating your diabetes control.
- Every six months after: another visit documenting your adherence to the CGM regimen and treatment plan, to keep coverage going.
- A pharmacist does not count as the treating practitioner for this purpose.
Commercial plans usually want a recent relevant visit too, though the framing is less rigid. Either way: book the appointment before you start chasing the order.
Not sure where you land?
Tell us your situation and we will check the actual criteria your plan applies — free, no obligation.
What does not disqualify you
- Having type 2 rather than type 1. Medicare's policy does not distinguish between them; it asks about insulin use and hypoglycemia.
- Being newly diagnosed. There is no waiting period.
- Having used a different CGM before. Switching brands is routine.
- Not owning a receiver. The G7 works with a compatible smartphone; the receiver is optional.
What genuinely makes it harder
- No insulin and no documented lows. This is the main gap. Medicare will not cover a CGM here, and commercial coverage is roughly a coin flip — Dexcom reports about 50% of non-insulin users have coverage.
- Prediabetes or no diabetes diagnosis. Not covered, and also excluded from Dexcom's free trial — which in any case is limited to commercial insurance and excludes Medicare, Medicaid and VA beneficiaries.
- A plan that prefers another CGM brand. Workable through a formulary exception, but an extra step. See the insurance guide.
If you fall into the first two groups and still want continuous glucose data, Dexcom's Stelo biosensor is sold over the counter without a prescription for adults who do not use insulin. It is a different product from the G7, and it is not indicated for people with problematic hypoglycemia — so it is not a substitute if lows are your reason for wanting a CGM.
If you do not qualify for coverage
You can still buy a G7 with a prescription and pay cash. Retail runs roughly $500–$575 a month, and Dexcom's coupon or a discount card typically brings that to about $180–$320. The cash price guide has the numbers, and the savings page covers Dexcom's assistance program for people with limited income.
Frequently asked questions
Can I get a G7 if I have type 2 diabetes and take pills, not insulin?
Your doctor can prescribe one. Coverage is the harder part: Medicare would require documented problematic hypoglycemia, and commercial coverage varies. Ask your plan directly, and if the answer is no, compare cash options.
Does my A1C matter?
Not for Medicare's CGM criteria, which turn on insulin use or hypoglycemia rather than an A1C threshold. Some state Medicaid programs and commercial plans do set A1C-based criteria, so it can matter depending on your payer.
My doctor has never prescribed a CGM. Where do I start?
Ask at your next diabetes visit, and bring specifics: how often you test, what your lows look like, and whether anyone has had to help you during one. Those details are what a prescriber needs to document.
A checklist to take to your appointment
Coverage decisions rest on what is written in your chart, not on what you remember. Bringing specifics to the visit is the single highest-leverage thing you can do. Be ready to say:
- Your insulin regimen, if you use insulin — which insulins, how often, and for how long.
- How often you test now, and what your typical numbers look like.
- Your low blood sugar history in detail: roughly how often, how low the readings went, what time of day, and critically — did anyone have to help you? Ask that these be recorded with dates and glucose values.
- Whether you have hypoglycemia unawareness, meaning you stop feeling lows coming. This is clinically important and worth stating plainly.
- What you want and why: fewer fingersticks, overnight alerts, data to share with the clinic.
“I have bad lows” is not documentation. A payer reading your chart is looking for glucose values, dates, and whether third-party assistance was needed. Vague notes are the most common reason an otherwise qualifying patient gets denied.
Special situations
- Gestational diabetes. Some payers, including a number of state Medicaid programs, have added CGM coverage for gestational diabetes. It is not universal — check your specific plan rather than assuming either way.
- Newly starting insulin. You meet the insulin branch from the moment you are treated with insulin; there is no waiting period. Getting the CGM started alongside insulin is often easier than adding it later.
- Switching from another CGM. Routine. What can complicate it is a plan that prefers the brand you are leaving — that is a formulary exception conversation, not an eligibility problem.
- Type 2 on oral medication only. This is the hardest case for coverage. Medicare requires documented problematic hypoglycemia; commercial coverage is roughly even odds by Dexcom's own numbers. Worth asking, worth appealing, and worth comparing cash options if the answer is no.
What happens after you qualify
Qualifying is not the same as having sensors. There is still a prescription to write, possibly a prior authorization to clear, and a decision about which benefit and which supplier to use — and on Medicare, a six-month follow-up visit that has to keep happening for coverage to continue. Our four-step guide walks through the rest of it, and the insurance page covers what to do if a claim is denied.
If the answer is no
It is worth saying that a coverage denial is not a judgment about whether a CGM would help you. It is a payer applying a rule. If you do not qualify:
- Ask why, specifically. If it is a documentation gap, it is fixable. If it is a genuine exclusion, at least you know.
- Ask about the assistance program. Dexcom's income-based program exists for people in exactly this position.
- Compare cash prices properly. Roughly $180–$320 a month with a discount card is a real expense, but it is a long way from the $500–$575 retail figure people assume.
- Revisit it if things change. Starting insulin, a documented severe low, or a new plan year can all change the answer.
Sources: CMS LCD L33822, CMS Policy Article A52464, Dexcom cost & coverage, FDA — OTC CGM clearance.