Getting Insurance to cover the Cgms..

[Tony]

So last Thursday my Dr.'s office faxed a letter of medical necessity to my insurance which is BlueCross BlueShield of RI. Today I called my insurance only to find out I was denied for the cgms(minilink). However, the lady I spoke with encourage me to appeal this decision. She repeated herself a couple times to me, to make sure I do appeal. She said most of the time they will approve it.

Once I receive the denial letter I can then fax my appeal in. I need to send the denial letter along with a letter stating why I need the cgms.

Has anyone been at this stage of the game and won the appeal? This is my last chance so I like to make sure I come out winning. Any advice will be very much appreciated!

[rmccully2000]

Tony, I know of a mom who won on appeal from UHC.
Here is a link to a thread where she talks about it.

Getting Insurance Company Approval - Children with Diabetes Forums (http://forums.childrenwithdiabetes.com/showthread.php?t=3008)


Have they stated the reason for denial? It could be that you just need to send in the more recent studies for all 3 CGMS. Many insurance companies are still looking at the old MM Gold/Glucowatch data. I believe this is what Emma's mom did. She also sent in graphs from the MM CGM showing instances where she prevented lows.

Personally, whatever reason they give you, I would stress that CGM data (direction and rate of change) will make dosing a dangerous drug (insulin) much safer. Some of us have compiled arguments at the Yahoo CGM Group.

Then detail the costs associated with severe hypos and hypers plus the costs of diabetes related conditions (all of which can be prevented or greatly reduced with CGM data). Compare these costs to the yearly cost of sensors... there is a big difference. I had the EOB from Mason's dx ready to send in ($35,000) and that did not include any time in ICU (thankfully :) )

Best of luck!! I'm keeping my fingers crossed for you!
Becky, Mom to Mason, 7 Dexcom, Iport

[kgm0612]

Good luck Tony.........I hope you win your appeal and B/C approves it for you.

Karen

[Tony]

Here is the insurance's reason for denial.
The items have not been approved as requested because your request for the Continuous Glucose Monitoring System(CGMS) does not follow our guidelines for coverage. Our policy allows for a standard model of a home glucose monitoring system. Methods of Continuous of Monitoring Glucose levels are not covered because there is insufficient clinical evidence in published peer-reviewed medical literature to support a conclusion concerning the health of outcomes or benefits associated with this treatment. Therefore, this request will not be reimbursed.

Now I need to find published clinical evidence to support the cgms and go from there, if there is any.

[JediSkipdogg]

Now I need to find published clinical evidence to support the cgms and go from there, if there is any.

There partially is in terms of lowered A1Cs. There is the Star 1 and Star 2 trials that were conducted in Europe by Medtronic. I know Star 2 was just completed or just published (I think completed) this past December. Star 3 is one that is ongoing and is suppose to be the dealbreaker for insurance companies howerver it's a 5 year trial that is only in about year 1-2. So it'll be a while before that one takes place.

Good luck finding the Star studies though.

[Twister212]

UNH has decided to approve these products. Don't know about Dex, but definitely Minimed. Still need letter of medical necessity.

[rmccully2000]

Here is the insurance's reason for denial.


Now I need to find published clinical evidence to support the cgms and go from there, if there is any.

Oh, this is probably referring to the old Glucowatch/MM Gold studies. There have been many studies in the past 2 years to help you.

At the bottom of this page children with DIABETES - Continuous Glucose Sensors (http://www.childrenwithdiabetes.com/continuous.htm) is a collection of study links that you should submit with your appeal.

JDRF has also created a step by step guide to getting coverage here: Case by Case CGM Coverage : Juvenile Diabetes Research Foundation International (http://www.jdrf.org/index.cfm?page_id=106514)

Oh, another one of my favorite research sites: Entrez PubMed (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?DB=pubmed) You can find the Direcnet studies here too.


And another I just remembered seeing but haven't read yet. A book about fighting insurance battles. Looks good and I think I'll get later this year. The Insurance Warrior (http://www.theinsurancewarrior.com/)
Best of luck Tony!
Becky, Mom to Mason, 7 Dexcom, Iport