Appealing the cgms

[Tony]

As you know from another thread I started a month ago I was denied coverage for the continuous glucose monitoring system (cgms). I am now in the process of appealing and I am pretty confident that I will win my appeal. Here's why,

The basis for my appeal is that the cgms is covered pursuant to the General Laws of the State of Rhode Island, 1956, as amended, §27-18-38(a)(b), entitled “Diabetes Treatment” which states, in part “Upon the approval of new or improved diabetes equipment and supplies by the Food and Drug Administration, all policies governed by this section shall guarantee coverage of new diabetes equipment and supplies when medically appropriate and prescribed by a physician.”

Now your probably asking yourself, does my state have a similar law?

46 states have some type of laws requiring health insurance coverage to include treatment for diabetes and the four states that do not included coverage are Alabama, Idaho, North Dakota and Ohio.

I have found California and Texas have a similar law to Rhode Island where health plans must provide coverage for new or improved diabetes equipment and supplies approved by the FDA when determined by a physician to be medically necessary and appropriate.

[BriOnH]

Holy #@$ that is awesome. I can't wait to use that with my insurance!

[xMenace]

How about Canadian provinces?

[Tony]

How about Canadian provinces?
I don't know, I only researched the states.

[someone]

Where did you find this information?

[someone]

Ok, I researched this law in Texas. I found the following relevant information in Chapter 21, sub chapter R of the Texas Administrative Code.


(b) As new or improved treatment and monitoring equipment or supplies become available and are approved by the United States Food and Drug Administration, such equipment or supplies shall be covered if determined to be medically necessary and appropriate by a treating physician or other practitioner through a written order.

http://secure.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=28&pt=1&ch=21&rl=2605

I also found the following on the Texas Department of State Health Services website.


What types of health benefit plans are not required to cover equipment, supplies, medication, and self-management training?
Self-funded plans are not governed by the Department of Insurance; they are not required to cover these items, although they could, depending on the terms of the policy.

http://www.dshs.state.tx.us/diabetes/dcinsure.shtm

I think it is quite clear that CGMS is not "necessary" (or is it?) regardless of what your doctor says, but either way, I do not even have Texas insurance.

Good luck with that..

[ant hill]

If you buy a pump or CBGM and you buy without insurance then you are in for a shock as the price is phenomenal. :eek:
With insurance the manufacturer are bound by the insures price so the insurance dictates weird!!. :confused:

[Tony]

I think it is quite clear that CGMS is not "necessary" (or is it?) regardless of what your doctor says, but either way, I do not even have Texas insurance.

Good luck with that..

You must have some form of insurance, right?

The following is from the Texas insurance code chapter 1358. Diabetes subchapter A.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Sec.A1358.054. COVERAGE REQUIRED.AA(a) A health benefit plan
that provides coverage for the treatment of diabetes and conditions
associated with diabetes must provide to each qualified enrollee
coverage for:
(1)AAdiabetes equipment;
(2)AAdiabetes supplies; and
(3)AAdiabetes self-management training in accordance
with the requirements of Section 1358.055.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Sec.A1358.056. COVERAGE FOR NEW OR IMPROVED EQUIPMENT AND
SUPPLIES.AAA health benefit plan must provide coverage for new or
improved diabetes equipment or supplies, including improved
insulin or another prescription drug, approved by the United States
Food and Drug Administration if the equipment or supplies are
determined by a physician or other health care practitioner to be
medically necessary and appropriate.

[Harold]

Think this needs to be stuck, so I did it. :D

[Doug]

Many companies insurance is "self funded"
That means that United health care or someone else manages and processes the claims and just sends a bill to the company
I know that our insurance is self funded so we would not get the benefit of the above Texas statements

[someone]

Here is the applicability of the diabetes subchapter


§ 1358.052. APPLICABILITY OF SUBCHAPTER. This
subchapter applies only to a health benefit plan that:
(1) provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or sickness,
including:
(A) an individual, group, blanket, or franchise
insurance policy or insurance agreement, a group hospital service
contract, or an individual or group evidence of coverage that is
offered by:
(i) an insurance company;
(ii) a group hospital service corporation
operating under Chapter 842;
(iii) a fraternal benefit society operating
under Chapter 885;
(iv) a stipulated premium company operating
under Chapter 884;
(v) a reciprocal exchange operating under
Chapter 942; or
(vi) a health maintenance organization
operating under Chapter 843; and
(B) to the extent permitted by the Employee
Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
seq.), a health benefit plan that is offered by a multiple employer
welfare arrangement as defined by Section 3 of that Act; or
(2) is offered by an approved nonprofit health
corporation that holds a certificate of authority under Chapter
844.

Added by Acts 2003, 78th Leg., ch. 1274, § 3, eff. April 1, 2005.


The following definitions are also listed in 1358.051.


(1) "Diabetes equipment" means:
(A) blood glucose monitors, including
noninvasive glucose monitors and glucose monitors designed to be
used by blind individuals;
(B) insulin pumps and associated appurtenances;
(C) insulin infusion devices; and
(D) podiatric appliances for the prevention of
complications associated with diabetes.
(2) "Diabetes supplies" means:
(A) test strips for blood glucose monitors;
(B) visual reading and urine test strips;
(C) lancets and lancet devices;
(D) insulin and insulin analogs;
(E) injection aids;
(F) syringes;
(G) prescriptive and nonprescriptive oral agents
for controlling blood sugar levels; and
(H) glucagon emergency kits.


It looks like you might be able to get coverage for the device itself, but there is nothing listed under the supplies section that would include sensors. They specifically say test strips under supplies.

[Tony]

Many companies insurance is "self funded"
That means that United health care or someone else manages and processes the claims and just sends a bill to the company
I know that our insurance is self funded so we would not get the benefit of the above Texas statements

Actually I know someone in RI who just won an appeal with united health by using this law in his appeal. Although He wasn't helpful in providing me with any of this information but, luckily I do have a connection that was more then helpful with providing the general laws of RI for diabetes treatment.

[rmccully2000]

Thanks Tony! We already have coverage in Texas but that is so good to know for the future

Someone: I believe everyone on insulin can prove medical necessity, regardless of "control" or A1C. Anything less than continuous data is guessing, which is more art than science. Continuous data puts a little science into the equation, allowing more precise dosing.

I am serious when I say, that I would do whatever it takes to keep a CGM on my son. Now I know why I was such a nervous wreck on finger pokes alone LOL!!

Becky, Mom to Mason 7 Dexcom

[Tony]

It looks like you might be able to get coverage for the device itself, but there is nothing listed under the supplies section that would include sensors. They specifically say test strips under supplies.

The sensors are not going to be listed. This law was put in to effect before the cgms was fda approved. This section covers the sensors. Sec.A1358.056. COVERAGE FOR NEW OR IMPROVED EQUIPMENT AND
SUPPLIES.AAA health benefit plan must provide coverage for new or
improved diabetes equipment or supplies,

[someone]

Well.. good luck Tony. Right now my insurance is in IL, but I will probably be switching soon.

[kgm0612]

Tony...........I PM'd you earlier this morning and gave you my email addy so you can send me any information you have on this. I'll pass it onto my endo and go from there.

United Healthcare keeps telling me NO, but to be perfectly honest with you, I'm finding that the people I'm talking with at United have NO CLUE what a CGMS is! I'm still having payment issues with them. They deny my claims every month, requesting more information as to why I need 300 test strips a month.

Karen

[jeggeman31]

I'm finding that the people I'm talking with at United have NO CLUE what a CGMS is!

I will agree with you on that. They told me that a CGMS has nothing to do with diabetic care.

[jeggeman31]

As you know from another thread I started a month ago I was denied coverage for the continuous glucose monitoring system (cgms).


Is there an insurance code yet for this? Last time I talked with MiniMed they told me not yet.

[kel4han]

Alot of the problem is that it has to be deemed "medically necessary" by your physcian, so if you have a good A1c, stability, and awareness, it can be really hard to convince your Endo that you should have one, and they are not willing to spend thier time fighting for the CGMS unless you have "difficult" or poorly managed diabetes. Example: My 6yr old does not have documented unawareness, or a terrible A1c since diagnosis 6months ago. So, Her endo doesnt see why we would want/need a CGMS, they have no documentation to prove we should be considered medically necessary since we are "doing well" therefore, they really have nothing to present to the insurance. :mad:
Of course we all know just having this stupid disease itself is reason enough. :mad:

[kel4han]

Oh....and I posted in another thread the billing code needed for CGMS is A9279 a Misc or Invesigational HCPCS code. Definition is: Monitoring feature/device stand alone or INTEGRATED, any type, includes all accessories, components and electronics not otherwise classified. Per the 2007 HCPCS professional coding book I use at work. :)

[Type1er]

Many companies insurance is "self funded"
That means that United health care or someone else manages and processes the claims and just sends a bill to the company
I know that our insurance is self funded so we would not get the benefit of the above Texas statements

How do you find out if your company's plan is "self funded"? Is there a document that you can look at, or do you just have to ask the benefits people and hope you get the correct answer?

By the way, thanks for making this thread sticky. I think this info here will help a lot of people!

[kgm0612]

Oh....and I posted in another thread the billing code needed for CGMS is A9279 a Misc or Invesigational HCPCS code. Definition is: Monitoring feature/device stand alone or INTEGRATED, any type, includes all accessories, components and electronics not otherwise classified. Per the 2007 HCPCS professional coding book I use at work.

Thanks so much for this info. Maybe this will help some of us out! My A1c has climbed to 7.3 over the last 16 months that I have been pumping. My endo is more than willing to go above and beyond in helping me get United to pay for the CGMS.

I will agree with you on that. They told me that a CGMS has nothing to do with diabetic care.

Jim.........I knew I was in trouble when I had to explain to the first rep what an insulin pump was! My opinion is that when we call our insurance companies on a medical issue.....be it diabetes, cancer, etc........they should have specialists with knowledge of that disease so that they can better help us!

Karen

[someone]

My endo is more than willing to go above and beyond in helping me get United to pay for the CGMS.

I don't think I have a problem there either. My endo said he was willing to get "certified" by Dexcom so that I could get on it, but suggested that I wait for the MM one. Surely he would help me get insurance coverage..

[Raisin]

Tony,
Did you do your research on-line? If so, did you Google a search term which got you to the right governmental code sections? I leave in NC and I am about to have Minimed try and get Blue Cross to cover the sensors. If they deny it, I want to appeal as well and want to send them my State statute if I can find it. Thanks, Dale

[someone]

I leave in NC and I am about to have Minimed try and get Blue Cross to cover the sensors.

I doubt Minimed will help you.

[Tony]

Tony,
Did you do your research on-line? If so, did you Google a search term which got you to the right governmental code sections? I leave in NC and I am about to have Minimed try and get Blue Cross to cover the sensors. If they deny it, I want to appeal as well and want to send them my State statute if I can find it. Thanks, Dale

I have a connection with a lawyer who looked up the law in RI and he also had some information on other states as well and then I found some information online.

You can google " your state law diabetes " and that will bring up any state laws on health insurance coverage for diabetes treatment.

As I said in the first post, there are four states that do not have laws requiring health insurance coverage for diabetes treatment.

[Tony]

Update on my appeal for the CGMS.

The insurance company denied the cgms again even though I meet medical criteria for the CGMS. Their policy guidelines states they only cover two in a calendar year and I'm looking for long term use.


Our medical director, a board certified physician, has again reviewed the medical necessity of the services referenced above. Based on the information provided, the services referenced above for the Continuous Glucose Monitoring System (CGMS) continues to be denied.

Reimbursement for services remains denied because although the member does satisfy BCBSRI medical criteria for cgms coverage, his request is for long term continued use of cgms. BCBSRI policy guidelines, limits coverage of this item to two times in any calendar year.

[JediSkipdogg]

Tony, it sounds to me like they may have no idea what you are fully talking about. What it seems like they think is you are using the old Guardian at a doctor's office. Therefore they are looking at the cost of that. And in those terms, that cost is ALOT greater. It's like $250 for a 3 day wear. So instead of $5200 a year, they are thinking $30,000. Just a thought that maybe you could use if you decide to appeal again. Explain that it is a device that is home use and does not require expensive doctor visits anymore than you have now.

[KickStart101]

Update on my appeal for the CGMS.
The insurance company denied the cgms again even though I meet medical criteria for the CGMS. Their policy guidelines states they only cover two in a calendar year and I'm looking for long term use.


Geez Tony, I'm sorry to read of your denial again.
Interesting note though.

If the Companies would stop charging so much
for all these new gadgets, I don't think Insurance
companies would be denying People these items.
After the first couple thousand are produced, it
normally costs much less to produce the others.

Kevin could be right about them not realizing the
true cost...or was the cost mentioned?

I've heard of the CGMS but I haven't actually
read up on them so I'm not knowledgeable on
the length of time for their usage. :rolleyes:

Since I don't know what I'm talking about, get
your Dr. to make out 1 prescription for the CGMS
for 6 mths. and a 2nd prescription for 5 or 6 mths.
every year. Or something similar. If they can play
with words...so can you.

If this message makes zero sense or does not apply,
please disregard. ;)

I do hope that you can figure a way to get a CGMS.
Good Luck.

[BlueSky]

.... The insurance company denied the cgms again even though I meet medical criteria for the CGMS. ....
Maybe I have missed something here. But what is the medical neccessity? Are you saying that you are unable to manage your control in the normal way?

I can see that a CGMS could be useful with children. And with people who, for whatever reason have very erratic control. But for the vast majority of us, moderating carb consumption and the corresponding insulin dosing is all it takes to manage glyceamic control without the benefit of high tech gadgets.

I guess I am playing devils advocate here because a lot of people seem to be getting caught up in high tech hype, the benefits of which are marginal and very expensive. Where I live, non of this stuff (pumps, CGMS) is funded. And, generally speaking, we are not any worse off for not using it.

[JediSkipdogg]

Maybe I have missed something here. But what is the medical neccessity? Are you saying that you are unable to manage your control in the normal way?

Here in the USA if you want something generally over $750 you have to prove that it is medically necessary. For me, a pump WAS NOT medically necessary but more of a convenience option when I was in college. However, I had to prove it was medically necessary to get insurance ot pay for it. Now that I look back and haven't had an ER visit in almost 4.5 years, I see the benefit of the pump.

I guess I am playing devils advocate here because a lot of people seem to be getting caught up in high tech hype, the benefits of which are marginal and very expensive. Where I live, non of this stuff (pumps, CGMS) is funded. And, generally speaking, we are not any worse off for not using it.

Generally that is true here. For the most part I think MDI and testing once before every meal is fine. Hundreds of thousands did that for 50+ years and have ZERO complications. The problem is, it's not really the best option. And sometimes, in a case like me, carrying shots around is not convenient and don't offer the control I need for my current job. So it's taking what is out there and using it to make our lives more enjoyable and not so much thinking about diabetes all the time.

[kgm0612]

Our medical director, a board certified physician, has again reviewed the medical necessity of the services referenced above. Based on the information provided, the services referenced above for the Continuous Glucose Monitoring System (CGMS) continues to be denied.

Doesn't sound to me like this "board certified physician" is an ENDO!


Reimbursement for services remains denied because although the member does satisfy BCBSRI medical criteria for cgms coverage, his request is for long term continued use of cgms. BCBSRI policy guidelines, limits coverage of this item to two times in any calendar year.

I agree with Jedi.........they must be talking about the old Guardian. I'd appeal again, Tony, and this time I'd mention to the Medical Director that you'd like him to review your appeal with an Endocrinologist!

Good luck and keep us posted on what you decide to do.

Karen

[JediSkipdogg]

Doesn't sound to me like this "board certified physician" is an ENDO!

Generally they have NO specialists on the boards. Most of the times I think they are just GPs. I had a problem when I first had my insurance I have now. ALL synthetic fast acting insulins were at the highest tear. The long actings were at the middle tier. I questioned that and was told numerous times to just use Lantus and put that in my pump. Yeah, just what I wanted, 24 hours for the insulin to work, lol. I questioned that alot and eventually got the prices dropped down due to informing them of the difference and the requirement of a fast acting insulin.

[NoelD]

Tony, I got the same thing from BCBS of GA. They paid for the starter kit, and then another box of 10 sensors. I was then notified they normally don't pay for "kits" and they would no longer pay for sensors. My Dr, insurance agent through work, and I hounded them to no avail. Ah, I gave up. I get 2 weeks roughly out of each sensor now, so it's not too bad to me.

[camjen1]

I guess I am playing devils advocate here because a lot of people seem to be getting caught up in high tech hype, the benefits of which are marginal and very expensive. Where I live, non of this stuff (pumps, CGMS) is funded. And, generally speaking, we are not any worse off for not using it.


What's wrong with using something new that might improve overall control?

There is a reason why these "high tech" gadgets are being made, it's for us diabetics to be able to use and learn from it. I don't see anything wrong with doing such. Just because one doesn't like the idea of "high tech" gadgets doesn't mean they should put a damper on others treatments.

In all honesty, if the "high tech" gadgets as you say were funded where you live would you stick to the same ole MDI and glucose monitors or would you give a CGMS a shot?

[BlueSky]

What's wrong with using something new that might improve overall control? .... if the "high tech" gadgets as you say were funded where you live would you stick to the same ole MDI and glucose monitors or would you give a CGMS a shot?
Oh, there is nothing wrong with the high tech stuff. It is all good, powerful technology. The issue is : is it reasonable to expect someone else to pay for this expensiev technology to be put into general use, if it is only making peoples lives a bit easier? If pumps were funded here, I would get one tomorrow. Customising my basal rate would definitely improve my control. Having said that, satisfactory control (HBA1c <6.5%) is possible without the pump. It just takes more work. I could not justify personally spending that kind of money to make my life a bit easier. So I am not surprised that the district health board is putting it's limited resorces into areas that provide a better public health payback. :o

[Dewey]

Having said that, satisfactory control (HBA1c <6.5%) is possible without the pump.
I'm sorry, but I Totally disagree here. As someone who has been on both shots & pump therapy, I had very problematic control before starting on the pump (A1Cs of 8s, 9s, and higher), and we tried Everything imaginable, including up to 6 shots per day! Once I started pump therapy, my A1Cs dropped to the 4s, 5s & 6s! BIG difference!

Not Everyone can achieve satisfactory control without the use of pump therapy, and it is my belief that things should be looked at on a case by case basis, rather than as a whole.

[NoelD]

I agree Dewey. My A1C never went below 9.0 on MDI no matter what I did. Now, it's 5.3 since the pump/cgms combo.

[condensr]

There is an incentive financially for insurance companies to cover CGMS systems, too:

Which costs more, one visit to the ER for a severe hypo, or a CGMS system? I think the ER visit is more.

If these systems save just ONE ER visit for a high/low then they have pretty much paid for themselves. Also, while they can't replace fingersticks for treatment decisions, they sure can cut down the amount of expensive strips used when one is trying to get a good idea of their patterns and testing all the time for it.

I was denied coverage for these as well (twice!) and I have coverage that is considered some of the best around. I have one more appeal (to our benefits administrator, as our plan IS self-funded) but Premera BC has just plain said no, it's not medically necessary. They don't agree with one of the most distinguished endos around that says it is, and prescribed it.

[BlueSky]

.... I had very problematic control before starting on the pump (A1Cs of 8s, 9s, and higher), and we tried Everything imaginable, including up to 6 shots per day! Once I started pump therapy, my A1Cs dropped to the 4s, 5s & 6s! BIG difference!....

But then you started the pump back in the bad old NPH days. Have you tried Lantus oir Levimer. My HBA1c was also 8+% when I was on NPH. Some dietary changes and switching to Lantus brought it down below 6.5%. A pump wasn't neccessary. They don't call Lantus the "poos man's pump" for nothing. :o

[someone]

I was able to get 5.5-6.5 a1cs on MDI. My highest was 7.1, and that is my highest ever. A lot of it also depends on things like activity level. I always noticed my highest a1cs when I wasn't very active (that applies to pump and MDI).

As for CGMS, it has not only been a convenience, but has revealed patterns in my BGs which I would have never discovered. I haven't had an a1c test since I began using it so I have yet to see if I have improved... it's hard to beat a 5.6. In my case I think it has been more a matter of stability.

[JediSkipdogg]

Which costs more, one visit to the ER for a severe hypo, or a CGMS system? I think the ER visit is more.

I have to disagree with that. And here is my reason. Say you are 25 years old and you are going to live till you are 75. You want a CGMS and we will put that price at $1000. Using the standard 4 year pump replacement warranty terms, that means you will use 13 CGMS units in your lifetime. That's $13000 without considering inflation.

Now, let's look at the sesnors. Insurance companies have to follow FDA guidelines and prices for what is ut there now. So a sensor is $35 for 3 days of wear. In 50 years, one will be allive 18250 days roughly therefore using 6084 sensors. That means those sensors will cost $212,917.

Total price based on today's values for a CGMS is $225,917 ($4518.34 per year). The average price for an ER visit was $202 in 2002 (I couldn't find today values but I searched briefly) and for an ER admit was $8,049.

Unless you visit the ER numerous times a year (which would put you at brittle diabetes) the CGMS is not cost effective. So that is why they are very careful in who they prescribe this too. Someone like me that hasn't been in the ER in 8 years would be a downfall to the insurance company. Now if my record showed 3 admits in the past year, then they may think twice and just give it to me.

That's my 2 cents.

[Tony]

The thought has crossed my mind with the insurance being a little confused on what I'm trying to have covered but, the medical necessity letter did state I was looking to have the minilink and sensors covered. You would think though, they did their home work on the minlink. I also think this is their way of not covering the system. I will see the Dr. next month so I will have him contact the medical director to be sure we are on the same page.

The medical necessity is that I can't get my a1c below 8% and with the work I do I never know when we are going to be active or not. My activity level is different every day. It's not like I go to work and sit at desk all day doing the same exact thing at the same time every day.

[Belinda]

Way to go Tony...push them and stay on them.

Their medical director probably is one of those that think diabetes can be treated with insulin only. I had the same problem with my insurance when the misfortunate removal of my toe came into play....they stated I no longer needed hospital stay for the infection....which I needed the whirlpool therapy. After arriving home and I called BCBS the nurse read to me the denial of hospital stay.....also read that I could possibly lose my foot or leg below the knee.....this is when all **** broke loose. Needless to say it was their "physicial" that read the report....I told her he didn't know me NOR has he ever examined me. My doctor stated that I NEEDED the treatment and who was he to second guess him a physician that knew me and was working with me. I pushed and pushed and finally got the rehab needed. On my next surgery on the same foot I stayed a week in the hospital....they only approved 24 hours but the doc said that NO I was staying until I was ready and he was ready to send me home to heal.
Once again they didn't want to pay the bill but were backed up against the wall.

You keep pushing and pushing and finally they will see that you are only trying to save them money by taking the best possible care of yourself and your diabetes.

[camjen1]

But then you started the pump back in the bad old NPH days. Have you tried Lantus oir Levimer. My HBA1c was also 8+% when I was on NPH. Some dietary changes and switching to Lantus brought it down below 6.5%. A pump wasn't neccessary. They don't call Lantus the "poos man's pump" for nothing. :o


I was on Lantus and Humalog for about a year. I could not achieve an A1c lower then 7 no matter how hard I tried.

[NoelD]

But then you started the pump back in the bad old NPH days. Have you tried Lantus oir Levimer. My HBA1c was also 8+% when I was on NPH. Some dietary changes and switching to Lantus brought it down below 6.5%. A pump wasn't neccessary. They don't call Lantus the "poos man's pump" for nothing. :o

I was on Lantus and Apidra and switched to the pump with apidra.

[Dewey]

But then you started the pump back in the bad old NPH days. Have you tried Lantus oir Levimer. My HBA1c was also 8+% when I was on NPH. Some dietary changes and switching to Lantus brought it down below 6.5%. A pump wasn't neccessary. They don't call Lantus the "poor man's pump" for nothing. :o
Ummm, no. I was on Ultralente, Not NPH. While I had used NPH in the past, I was not on it the entire time prior to pump therapy. I had been using Ultralente for quite some time prior to pump therapy, and still was unable to achieve satisfactory A1Cs. Ultralente basically had the same attributes of Lantus or Levemir, in that it was a steady basal insulin.

Personally, I have absolutely No interest in trying Levemir or Lantus, or going back to MDIs. I've heard that Lantus can pool under the skin (which can cause absorption issues or cause a lack of proper absorption), and I'm not a big fan of putting yet more types of insulin into my body that contain that "wonderful" m-cresol (preservative). I have no qualms in taking shots or even doing the "untethered" regimen if & when needed (provided I can use Ultralente, not other types of long-acting), but since I've been doing quite well on the pump & have been able to achieve excellent A1Cs, why ruin a good thing!?

We need to realize that not everyone can be controlled via shots & shots alone. I'm just one of many who are "living proof" of that.

Tony, sorry if I distracted from your thread in any way, and I sure hope you get the coverage needed for your CGMS. Please continue to keep us posted on your progress regarding the MM CGMS. Your fight may help others who have problems getting theirs covered.

[cat_collector]

I have been working with my ins company since late April just trying to get a yes or no . Finally this week I got a supervisor that was a bit ticked that have been not geting back to me and dragging this out . I should have my answer Mon or Tue and I feel confident that they will cover it . It old her i was ready to just give up and she told me to NOT do that so if it is NO i will appeal it .

I have not been able to find a price on these can anyone give me an idea ?

Tracy

[JediSkipdogg]

I have been working with my ins company since late April just trying to get a yes or no . Finally this week I got a supervisor that was a bit ticked that have been not geting back to me and dragging this out . I should have my answer Mon or Tue and I feel confident that they will cover it . It old her i was ready to just give up and she told me to NOT do that so if it is NO i will appeal it .

I have not been able to find a price on these can anyone give me an idea ?

Tracy

The MM system is roughly $1400. The Dexcom is $800. The new Dexcom Seven (not available for purchase as it was just FDA approved a few weeks ago is $1300. The sensors are $35 for days wear foir both the MM and the original Dexcom and $60 for the Dexcom Seven.

Now, some may say those prices are different, however, those are the prices insurance companies MUST go by.

[cat_collector]

My CGMS was aprroved ! it only took since April but Im glad they finally got with it . I got a call from minimed and my Nurse case worker at my Ins co. They called my mail order Pharmacy to see if they would process it so I would have no co pay . Now I just wait bcs the sensors are on back order .If any one really wants this they should push there ins company sometimes it just takes persistance to get things done .

Tracy

[kgm0612]

Congratulations Tracy.........I hope the sensors aren't on backorder too long!

I have an endo appointment today after work and I'm going to talk to him regarding the CGMS. I'm also curious to hear from him if there's any "new & improved" items expected out on the market in the near future.

Karen

[kgm0612]

I saw the endo yesterday. He's going to write a letter of necessity for the CGMS but already warned me that United Healthcare has been denying them. I'm going to put in a call to United today and want to speak to an information specialist, not just a rep. My endo wants the name & address of the person he should address the letter to.

A1c was 6.8, down from 7.1 three months ago. My blood sugars throughout the day are pretty good.........it's a roller coaster ride after dinner though. I hate this disease!

Karen

[nab486]

I have a question.... everytime I call BCBS they tell me Minimed has to call them... then I call Minimed and they say they can't call the insurance company .... am I not talking to the right people??? How do I get this ball rolling? I have already purchased the CGMS but would love to get the sensors covered.

[Worldcrzr]

By Googling California laws for diabetics, I found this link. It lists most of the states and their laws concerning diabetes supplies. Maybe it will help someone.

Diabetes: State mandates for insurance coverage (http://www.ncsl.org/programs/health/diabetes.htm)

[SPowell42]

My insurance company has the same verbage. It has nothing to do with the old Guarding. The insurance companies are trying to argue that if you use a CGMS for 3 days, twice a year, you can learn enough trend info to maintain your diabetes without having CGMS continuously.

Just another way they are trying to weasel out of this.

Scott

Tony, it sounds to me like they may have no idea what you are fully talking about. What it seems like they think is you are using the old Guardian at a doctor's office. Therefore they are looking at the cost of that. And in those terms, that cost is ALOT greater. It's like $250 for a 3 day wear. So instead of $5200 a year, they are thinking $30,000. Just a thought that maybe you could use if you decide to appeal again. Explain that it is a device that is home use and does not require expensive doctor visits anymore than you have now.

[dgrilli]

Anyone have any information for the State of Pennsylvania and I have United Health Care.

Does Pennsylvania have similar laws?

[RobiJo]

How/Where can I find this information for my state? (Michigan)

[Tony]

How/Where can I find this information for my state? (Michigan)
Here is the link for Michigan,
http://www.legislature.mi.gov/documents/1999-2000/publicact/pdf/2000-PA-0424.pdf

[Funnygrl]

Total price based on today's values for a CGMS is $225,917 ($4518.34 per year). The average price for an ER visit was $202 in 2002 (I couldn't find today values but I searched briefly) and for an ER admit was $8,049.



I have no idea what that ER visit included for $202 but I went to the ER for a hypo and my insurance paid $9000.

[dgrilli]

Here is the link for Michigan,
http://www.legislature.mi.gov/documents/1999-2000/publicact/pdf/2000-PA-0424.pdf

What about Pa? Tony

[kidvid]

I saw the endo yesterday. He's going to write a letter of necessity for the CGMS but already warned me that United Healthcare has been denying them. I'm going to put in a call to United today and want to speak to an information specialist, not just a rep.

Karen

I'm on United Health Care in Colorado - I called last week and they told me CGM was covered. I'm starting the application process this week.

Good luck,

Joe

[kgm0612]

Joe..........I have been waiting since July to hear something back from United Health. On Friday, I received a copy of a letter United sent to my endo requesting more patient information before a final decision is made.

I know this is going to sound strange...........A part of me wants the CGMS and a part of me is saying "wait". My thought is that within a short time a "new & improved" version will be out. So, if they decide to approve it now, I'll try it. If they don't, no big deal. I'll wait it out.

Karen

[someone]

I know this is going to sound strange...........A part of me wants the CGMS and a part of me is saying "wait". My thought is that within a short time a "new & improved" version will be out. So, if they decide to approve it now, I'll try it. If they don't, no big deal. I'll wait it out.

The Minimed monitor just came out about 6 months ago and the Dexcom seven shortly after. Relatively speaking, these are pretty new. Unless the already long awaited Navigator comes out soon, I think it'll be a decent amount of time before Minimed or Dexcom come out with something new.

[JediSkipdogg]

I know this is going to sound strange...........A part of me wants the CGMS and a part of me is saying "wait". My thought is that within a short time a "new & improved" version will be out. So, if they decide to approve it now, I'll try it. If they don't, no big deal. I'll wait it out.

The Minimed monitor just came out about 6 months ago and the Dexcom seven shortly after. Relatively speaking, these are pretty new. Unless the already long awaited Navigator comes out soon, I think it'll be a decent amount of time before Minimed or Dexcom come out with something new.

I'm in that same boat. However, MM is coming out with something new shortly. I can't recall if they are still in FDA approval but they are going for a longer sensor wear as well. To the average person that may not seem like a huge benefit to wait, but in my opinion it might be. At least if you have say a 5 day wear MM and it last 2 days all the time you can call the company up and complain. Where if you have a 3 day unit and they only last 2 days they will say that's good enough of a life. While it may just be a small software change to do that, I think it's huge enough that some should wait.

Now if one is waiting for another company to come out with one, I'd say it'll be a while. And someone, FYI...the MM Guardian RT came out in December but the unit prior to that was out a few years before that (the one that just gave numbers on the display, no graphs.)

[someone]

And someone, FYI...the MM Guardian RT came out in December but the unit prior to that was out a few years before that (the one that just gave numbers on the display, no graphs.)

http://www.diabetesforums.com/forum/pumping-insulin/17052-minilink-real-time-transmitter.html

It came out on 3/12 and I bought mine on 3/20. As far as I'm aware, the current stand alone RT was not sold prior to the release of the Minilink transmitter.

[JediSkipdogg]

http://www.diabetesforums.com/forum/pumping-insulin/17052-minilink-real-time-transmitter.html

It came out on 3/12 and I bought mine on 3/20. As far as I'm aware, the current stand alone RT was not sold prior to the release of the Minilink transmitter.

That's the smaller version of the transmitter. The CGMS pump system came out last summer and then the Guardian RT (that looks like the pump came out in December 2006. Before the Minilink the transmitter was this (which was non rechargeable, non battery replaceable, and lasted about 9-12 months)....

http://www.candiddiabetes.com/candid_diabetes/images/guardian_real_time_cgms_2.jpg

[someone]

That's the smaller version of the transmitter. The CGMS pump system came out last summer and then the Guardian RT (that looks like the pump came out in December 2006. Before the Minilink the transmitter was this (which was non rechargeable, non battery replaceable, and lasted about 9-12 months)....

http://www.candiddiabetes.com/candid_diabetes/images/guardian_real_time_cgms_2.jpg

Ok then.. I stand corrected. I didn't know the pump looking receiver was ever available with the original transmitter.

[Alaska]

My insurance has denied paying any of my pump supplies since I got the pump. They paid for the pump but not the supplies which I thought odd. So since I just FOUND this sticky I thought I'd look up Alaska state laws which reads as follows

Sec. 21.42.390. Coverage for treatment of diabetes.

(a) A health care insurer that offers in this state a health care insurance plan that includes coverage for pharmacy services shall initially and at each renewal provide coverage for the cost of treating diabetes, including medication, equipment, and supplies. All health care insurance plans must include coverage for outpatient self-management training or education, and medical nutrition therapy, if diabetes treatment is prescribed by a health care provider. The coverage required by this section is subject to standard policy provisions applicable to other benefits, including deductible or copayment provisions. Coverage for the cost of diabetes outpatient self-management training or education and for the cost of medical nutrition therapy is only required if provided by a health care provider with training in the treatment of diabetes.

SOOOOOOOOOOOOO......these jerks owe me some money. I've written the state insurance division and I'm contacting my lawyer the first of next week to get him on this. Chaps my butt........lol

Tony........I owe you a HUGE thank you for showing me the light

[palefacegirl03]

My insurance has denied paying any of my pump supplies since I got the pump. They paid for the pump but not the supplies which I thought odd. So since I just FOUND this sticky I thought I'd look up Alaska state laws which reads as follows

Sec. 21.42.390. Coverage for treatment of diabetes.

(a) A health care insurer that offers in this state a health care insurance plan that includes coverage for pharmacy services shall initially and at each renewal provide coverage for the cost of treating diabetes, including medication, equipment, and supplies. All health care insurance plans must include coverage for outpatient self-management training or education, and medical nutrition therapy, if diabetes treatment is prescribed by a health care provider. The coverage required by this section is subject to standard policy provisions applicable to other benefits, including deductible or copayment provisions. Coverage for the cost of diabetes outpatient self-management training or education and for the cost of medical nutrition therapy is only required if provided by a health care provider with training in the treatment of diabetes.

SOOOOOOOOOOOOO......these jerks owe me some money. I've written the state insurance division and I'm contacting my lawyer the first of next week to get him on this. Chaps my butt........lol

Tony........I owe you a HUGE thank you for showing me the light


I hope it works out, it is stupid to cover one thing and then not cover something else. If they covered the pump then they need to cover the supplies, it is that simple.

[modbom]

I just got approved by Oxford. Here's what minimed suggested I do with regards to my insurance company:

The first step when trying to get coverage on the Paradigm Real Time Continuous Glucose monitor is to ask for a single case negotiation. Get a case number, pre determination number, or pre certification number (different insurance companies call it different things) from an insurance company. It’s best to speak with a case manager, not the customer service rep that answers initial call. The patient should know what they are asking for so they should read the attachments prior to making the initial call.

Some questions that may be asked:

1. Diagnosis code-250.03 (this code is considered uncontrolled type 1 diabetes) 250.01 is type 1 diabetes- Juvenile Diabetes. You may ask you health care provider what your diagnosis code is.


2. Description and cost of item

Paradigm Real Time Continuous Glucose Monitor $999
Monthly ongoing cost of sensors $350
Code- this is where it gets tricky. We use a miscellaneous code to bill for this since it's such a new product for us. The code we use is E1399.

3. Date of Service- depends on availability. It’s safe to say one month after the conversation with the insurance company takes place.

4. Manufacturer information
Medtronic Minimed
18000 Devonshire Street
Northridge, CA 91325
phone- 800.933.3322
tax id- 954662001

5. If the insurance company says you do not need a case number or pre determination because it is a covered item, talk with someone else.


It’s usually a good idea to speak with a case manager that has a medical background. You will want to make sure they do not think you are asking for coverage for an insulin pump or a glucometer. They need to know this is a new device that has only been available since May 2006.

VERY IMPORTANT- Once you speak with a case manager, let them know your doctor would like to send in supporting documentation. Please get the fax number used to send in supporting documentation, case manager name, phone number, and extension. At that point in time, I usually work with the patient to get relevant health information to put together a letter. I email the letter to the educator, social worker, or doctor and they fax either to the patient or to the insurance company directly. If it goes to the patient I ask them to include blood sugar logs, the guard control trial, and hcp product description.

[KEVIN88GT]

funny that I found this thread.... I'm currently fighting with HIP healthplan of New York to approve the Minimed CBGM...

they denied me when I asked for it so I sent a letter to their Grievance and Appeal Dept (along with letter of medical necessity from my Endo and a letter from my stating I ended up in the ER from a hypoglycemic seizure resulting from hypounawarenes)

I called them up to find out the status and they said it was denied... I should be getting the official letter as to why shortly and will post what they said...

the lady on the phone basically summed it up as... They say they'll cover it for a one time use for like 10 days... so you could get your patterns and be done with it.... are they nuts? I had a hypoglycemic seizure because of hypounawarenes and I need thing thing ALL the time to make sure I dont bottom out at night..... what are these people smoking? The nurse from the DME dept actually said

"Why do you need to know what your sugar is every minute?"

I said "Would you rather me do 30 fingersticks per day?" I'm an RN myself...and found her to be a total moron...

I'll wait for the letter and post what they said here.... in the meantime my Endo is going to have me try the system for the 10 days that they DO cover it for....

[kgm0612]

I first started my quest for the CGMS back in July. United Healthcare has "misplaced" my paper work 2 times and keeps requesting more info from my endo. Last month, I threw in the towel. I've been pumping 2 years and have another two years left before I can get a new pump. By then, I'm figuring something "new & improved" will be out on the market. I've gone 5 years without a CGMS, what's another 2 years! LOL

Karen

[JediSkipdogg]

I first started my quest for the CGMS back in July. United Healthcare has "misplaced" my paper work 2 times and keeps requesting more info from my endo. Last month, I threw in the towel. I've been pumping 2 years and have another two years left before I can get a new pump. By then, I'm figuring something "new & improved" will be out on the market. I've gone 5 years without a CGMS, what's another 2 years! LOL

Karen

I actually took that same exact method. Why waste all my time fighting and then possibly have to fight if something better comes out next year. I would have even a harder time fighting then. I know the flaws with the current CGM technology, so in my opinion waiting is the best option. I've gone 25 years without it, what's a few more?

Twice now I think my doc's office has messed up. The first time they kept arguing with me that I needed to see the nurse educators first. And due to work I had to keep changing appointments and finally gave up on that. Then this second time I saw the educator, wasted an hour of my time, walked out and knew nothing more than before I went in, and still dont' have a CGM. I gave them all the appeal paperwork for the insurance company and haven't heard back from them so I'm assuming the doc's office never sent it in, and now the appeal time has expired.

[morrisma]

For dgrilli and any other PA cgms questers:

State of PA House Resolution No 197 of 2005 was the most recent but is not a requirement only a 'support of efforts'. HB 656 of 1998 is more comprehensive in that it required coverage for diabetes supplies.

Here's the link:
HOUSE BILL 656 P.N. 2505 (http://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=HTM&sessYr=1997&sessInd=0&billBody=H&billTyp=B&billNbr=0656&pn=2505)

Good luck,
Mike

[jky400e]

Karen,
I started my quest in October of last year. At that time the approval process was different and it sounds as though you are using that old process for approval.

I did out of pocket and then went for approval. It was backwards but it did work.
Currently the process or it was a few months ago is it is in MM hands just about 100%. United Health Care is one of the few that approves.
At the time I upgraded my pump with the trade in process, one year before a new one. And that is this next month.

I had a coworker that i showed the cgms to and he was approved and on cgms in 45 days. Long before i was so i just had to complain more.

The prescription from the doctor downloaded from MM
MM starts the process with UHC. The preauthorize
MM Then requested a copy of patient notes from my doctor and then sends to the person at UHC processing it.
Which that took just about 30 days, I think they lost it also. They have to dig and they were able to find each time i called and what went with it.

It took a long time to get reimbursed but i did.

I spoke to one person at UHC that deals with MM daily for this process. More of it is in MM hands.

Joe
T1 30 years
Pumping 24 years
CGMS march 2007

[scratch101]

Hrmn, seems I'm in this boat with y'all as well. Got approval a few months back for my CGMS (minimed, hooked up to my Paradigm 522) and everything was looking good, had my first 30 pack (3x 10) sets of sensors, and when I was finally getting near to ordering another supply from the 'distributor' I get a call from them telling me the supplies are no longer covered by my health insurance Empire BC/BS (for NY State employees). So I have a call in to them to see why they would approve the system/transmitter, but now not the sensors or the occlusive dressings.

Let the fun begin. :mad:

[purplestinker]

congratulations, sorry if I'm lost, which insurance cover it?

[KEVIN88GT]

Hrmn, seems I'm in this boat with y'all as well. Got approval a few months back for my CGMS (minimed, hooked up to my Paradigm 522) and everything was looking good, had my first 30 pack (3x 10) sets of sensors, and when I was finally getting near to ordering another supply from the 'distributor' I get a call from them telling me the supplies are no longer covered by my health insurance Empire BC/BS (for NY State employees). So I have a call in to them to see why they would approve the system/transmitter, but now not the sensors or the occlusive dressings.

Let the fun begin. :mad:

Cuz they want YOU to pay for it.... FIGHT THE POWER! (My insurance HIP in new york also covers it for like a 10 day try... as if thats going to help me, I will try it for 10 days see how it works for me... if the readings are accurate I'm taking them to court)

[KEVIN88GT]

guys I'm probably going to end up going to court through the state (New York) for a hearing regarding HIP Insurance denial the CBGM. I need to be prepared to do battle. What literature out there is there that shows the efficaccy of CBGM. I need things to show during the hearing when my insurance states "It's not a medical necessity"

[JediSkipdogg]

guys I'm probably going to end up going to court through the state (New York) for a hearing regarding HIP Insurance denial the CBGM. I need to be prepared to do battle. What literature out there is there that shows the efficaccy of CBGM. I need things to show during the hearing when my insurance states "It's not a medical necessity"

There isn't much research yet which is why the insurance companies have such a great foot to stand on. Currently there is only the Star 1 and Star 2 trials conducted by Minimed. Finding the results of those two study trials should be in some medical journals out there. That's about the only research to date and it's not really 100% effective research because it has people on MDI compared to people with pumps and CGMS combined. Which pumping alone can offer a significant improvement.

The Star 2 trials (estimated completion in 2010) will compare MDI users to pump users to CGMS users to pump & CGMS users. It's the only study being conducted on a widescale basis to show the true effectiveness of CGMS and pumping. I feel once that study is out (unfortunately gotta wait the time) then insurance will gladly pick up CGMS without question.

Sorry I can't be more help, but right now there is little research showing how great CGMS is. It's all a personal word of mouth and it varies at how much it can save insurance (if any.)

[Doug]

I applied for a Navigator here in Texas and as shocked when Abbott called 6 hours after I had given my nurse some final info to tell me that the Navigator was approved. I knew that there was NO way it happened that quick. I have UHC ins and had just had a new pump approved - After calling a few times I found that the "nurse" had called UHC and gotten the Prior authorization Number from the Pump and gave that to Abbott.

I called Abbottt back and told them to double check - sure enough The Young lady at the Drs office was wrong. In further research I found that she isnt a nurse but a "Medical Assistant" the dr cant afford to pay nurses on what the Ins pays.
So now Im starting back at square one - waiting for the paperwork to go thru and get considered for approval

With regard to the use of medical assistants - the fact that the Schools that train "medical assistants" advertise during Jerry Springer makes me nervous

[Pumped]

For anyone interested here's my experience/journey so far - I have a Minimed 715 and am trying to get coverage for the CGMS portion of the 722.

I'm part of Blue Cross Blue Shield North Carolg to BCBS.
Also, I'm working with my employer to try toina (BCBSNC) Medtronic faxed over a prior authorization request, which was basically a letter from my doctor talking about why the CGMS was good for me, to BCBSNC. Got a denial letter 2 days later. Now I'm drafting an appeal letter which I'll be sending directly to BCBS.

A second front of attack is trying to change my company's insurance plan coverage. My company has a self-funded insurance plan and they get to tell the insurance co. what to cover by making changes to the plan. I'm praying hard that they'll be able to do something.

Of course, I'll be sure to post updates here.