[JediSkipdogg]

Originally Posted by BlueSky

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.

Originally Posted by BlueSky

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]

Originally Posted by kgm0612

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]

Originally Posted by BlueSky

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]

Originally Posted by camjen1

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.

[Dewey]

Originally Posted by BlueSky

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]

Originally Posted by Dewey

.... 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.

[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]

Originally Posted by condensr

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]

Originally Posted by BlueSky

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.

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.