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July 27, 2025What to Look for in a CGM Medical Record Review
8 Essentials for an Audit-Proof CGM Medical Record Review
Reviewing medical records for Continuous Glucose Monitors (CGMs) isn’t just about checking a few boxes—it’s about ensuring every detail aligns with payer requirements. One small gap in documentation can result in claim denials or post-payment audits.
Whether you’re new to CGMs or scaling your offering, this guide walks you through exactly what to look for in a CGM medical record review to ensure every submission is complete, compliant, and audit-ready.
Disclaimer: CompliantRx is not affiliated with Medicare or CMS. This article is intended as a general guide based on publicly available information and should not be considered legal or billing advice.
1. Face-to-Face Evaluation
Ensure the provider conducted and documented a face-to-face visit that includes:
- Diagnosis of diabetes
- Documentation of insulin usage
- Evidence of the patient’s need for a CGM device
💡 Tip: The visit must be within 6 months prior to ordering the CGM.
2. Proof of Insulin Dependence
Most payers require CGM users to be insulin-dependent. The record should clearly indicate:
- Daily insulin usage (MDI or pump therapy)
- Insulin regimen details
👉 Look for phrases like “multiple daily injections” or “insulin pump therapy” in the clinical note.
3. Blood Glucose Monitoring Frequency
Payers often require documentation that the patient checks blood glucose 4+ times daily.
- This can be documented in provider notes or logs
- Confirm frequency over a consistent period (e.g. 14–30 days)
4. Treatment Plan Changes Based on Readings
The provider should make clinical decisions based on glucose levels, such as:
- Adjusting insulin dose
- Modifying medications
- Changing diet or lifestyle guidance
📌 This demonstrates the CGM is being used for active management.
5. Coverage Criteria Confirmation
Make sure the medical record supports all elements of Medicare or payer-specific LCDs (Local Coverage Determinations).
- Each criterion must be addressed clearly
- Use the MAC-specific LCD for your region (View LCDs here)
6. Correct Diagnosis Codes
Ensure the diagnosis codes align with documentation. Errors here are common and can trigger denials.
- E10.x for Type 1 diabetes
- E11.x for Type 2 diabetes
- Z79.4 for long-term insulin use
✅ Double-check for alignment between notes and claim form.
7. Signed and Dated Documentation
All entries must be signed and dated by the provider, including:
- Progress notes
- CMNs (if used)
- Addendums or updates
Missing signatures = incomplete documentation.
8. Clear Medical Necessity
Finally, the documentation should clearly answer: Why does this patient need a CGM?
- Recurrent hypoglycemia or hyperglycemia
- Hypoglycemia unawareness
- Daily glucose variability
📋 This statement can make or break reimbursement.
CompliantRx Tip
Even experienced teams can miss a detail—especially under time pressure. That’s why automated tools like CompliantRx’s AI Medical Record Review are designed to flag missing or unclear elements before submission.
Our platform checks every CGM record against your payer ruleset, giving your team real-time clarity and confidence.
Conclusion
A complete and compliant CGM medical record isn’t just about getting paid—it’s about building a process that avoids clawbacks, denials, and delays.
Use this checklist as a go-to guide before submitting any CGM documentation—and if you’re ready to scale your CGM offering with less risk, we can help.
Table of Contents
- What to Look for in a CGM Medical Record Review
- 1. Face-to-Face Evaluation
- 2. Proof of Insulin Dependence
- 3. Blood Glucose Monitoring Frequency
- 4. Treatment Plan Changes Based on Readings
- 5. Coverage Criteria Confirmation
- 6. Correct Diagnosis Codes
- 7. Signed and Dated Documentation
- CompliantRx Tip
- Conclusion
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What Our Clients Are Saying
Real Experiences, Real Results: How CompliantRx Empowers DME
Megan Dixon, Director
Time savings is valuable. If I save 20 minutes reviewing records, that is one more order that I can process in a day.
Matt Edwards, CEO
Medical record reviews are highly manual and time-consuming, making it easy to miss something. A tool like CompliantRx is a major perk for back-office efficiency and reducing human error.
