Help with CGM insurance codes?

[rmccully2000]

Hello, everyone,

I've recently purchased the Dexcom system and I'm getting my papers ready to file the initial claim. Everyone talks about how there are no codes for the equipment and sensors but I was curious and looked it up. I know that the MM Gold that was worn for 3 days and uploaded at the doctors office has been covered by insurance. I found the C codes listed at this site: http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp

If you open the 2006 Alpha-Numeric HCPCS File, there are two codes related to CGMS:

S1030 CONTINUOUS NONINVASIVE GLUCOSE MONITORING DEVICE, PURCHASE (FOR PHYSICIAN INTERPRETATION OF DATA, USE CPT CODE)

S1031 CONTINUOUS NONINVASIVE GLUCOSE MONITORING DEVICE, RENTAL, INCLUDING SENSOR, SENSOR REPLACEMENT, AND DOWNLOAD TO MONITOR (FOR PHYSICIAN INTERPRETATION OF DATA, USE CPT CODE)

Doesn't the first one seem to describe the Dexcom/MM RT? Is the word noninvasive the only reason people are saying that there are no codes for CGMS? I'm going to use this code in my claim/appeal because it is pretty darn close, but I'm just curious what other's opinions are on this. I'm confused!

Thanks,
Becky

[Tony]

I would think there is no codes on the cgms because the insurance isn't covering the system yet.

[rmccully2000]

Thanks! I realize they aren't routinely covering them and I'm going to fight for reimbursement. I know of 3 people who have won (2 on appeal, 1 on initial claim) so I'm going to try also.

I guess what I'm curious about is this code for cgms that already exists. There is alot of talk about the codes not being created until mid to late 2007 but when I searched I found some out there already (starting thinking maybe this was for the Glucowatch instead of MM Gold??)

Maybe they are talking about creating a new code, but taking out the word "non-invasive"? I just wondered why insurance companies can't use what's already out there.

I was thrilled to find this information since I can use this on my claim!! Now I just need to fight the 18 and over indication (it's for my son) and prove medical necessity. :) I've got the hair dye ready to cover the grey that is coming!!!

Thanks again,
Becky

[jrcskb]

Thanks Tony. I am also filing my initial claim/appeal. I started with an email, and I got a response today (over 1 week later). They are asking for a code. So, I may use one or both (and look for any possible others!).

[JediSkipdogg]

Can't you just call Dexcom and ask for the code? I know for the MM system they have no code and don't expect one till the end of the year. However, people have appealed and gotten insurance ot cover it. As you can tell, it's a long process.

[rmccully2000]

Thanks, I will call them again and ask about this. The rep basically told me I am on my own as far as applying for reimbursement so I'm not sure they will be any help, but it's worth a try.

Everything dealing with insurance seems to be a long process!! Of course it doesn't help that I have United Healthcare and they do not use case managers so I have to explain my story to a new person every time I call. What's scary is that some of the reps are clueless. I had to explain to two separate people what a cleft palate was !!! I'm willing to fight for it and our employer is self-insured and able to override any denials. We can always make the case to them if unsuccessful with UHC. Even if I don't like the Dexcom, I will have the process started. Then I will have everything done by the time (if!!) Navigator is approved available.

Becky

[rmccully2000]

I called UHC and asked if they had this code in their database. They do have it listed as a durable medical equipment code. :)

Anyone else out there trying to get coverage/reimbursement, if the insurer tries to tell you there is no code, I would give them this one and see what happens. It's worth a try until they get whatever new codes they are working on. It at least gives proof to the insurance that this technology is not new or experimental! You will probably still have to appeal but you might be able to fight the "no code" argument some are getting.
Becky

[kel4han]

S1030 is for non-invasive, meaning it does not penetrate the skin. The code A9279 is the code you are looking for in referring to the CGMS we would actually consider (minlink RT) Dexcom CGMS by sensor etc.

A9279 description is- Monitoring feature/device, stand alone or integrated, any type includes all accessories components, electronics, not otherwise classified.

This is from the 2007 HCPCS coding guidelines considered Misc, or Investigational coding.