[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]

Originally Posted by kgm0612

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]

Originally Posted by Tony

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.
Of course we all know just having this stupid disease itself is reason enough.

[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]

Originally Posted by 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

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]

Originally Posted by kgm0612

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]

Originally Posted by Raisin

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]

Originally Posted by 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

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]

Originally Posted by 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.

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.

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]

Originally Posted by Tony

.... 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.