[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]

Originally Posted by xMenace

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/pu...&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.
With insurance the manufacturer are bound by the insures price so the insurance dictates weird!!.

[Tony]

Originally Posted by someone

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.

[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]

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

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]

Originally Posted by someone

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.