[gettingby]

As some of you may know, I recently did a 3 day CGMS run. BCBSNC has denied my claim.
Reason for denial:
Request for coverage of 72-hour interstitial glucose monitoring is reviewed. Per Corporate Medical Policy BCBSNC will not provided coverage for continuous monitoring of glucose in the interstitial fluid. It is considered investigational and BCBSNC does not cover investigational services. Deny request for coverage as not medically necessary.

I honestly do not believe my endo would have suggested this to me if he had not thought it was medically necessary. The results he received from the monitoring is helping him to figure out why my A1C's have been staying high.
My question is this. Appeal or just let it go and pay the bill myself?
Thanks everyone for your opinions.

[shutterbug]

I think your insurance should cover it because the Dr wanted to do it. But, I don't know if they would consider your appeal though. They might just go by the books. However, its worth a shot!

[fgummett]

Do they cover other, "Investigational" procedures like blood tests, x-rays, MRI etc..? If yes, then why is this any different? I would ask the Endo for backing documentation and appeal it

[Holloway]

I have had problems with my insurance covering certain meds and have had to appeal, but in my case that just meant complaining to CMS (Medicare) about the insurance companies decision. It can't hurt to appeal. I know that the Social Security Admin will routinely deny claims for certain kinds of disability but that a huge majority of those claims are in fact approved after appeal.

If you have a copy of the contract with BCBS, see what it says about investigational treatments. With any luck there might be a clause that permits coverage when there is medical necessity. Even if there isn't, a court might decide that it should be covered as a matter of public policy - if you wanted to take it that far.

Also consider contacting groups that advocate for diabetic rights. Don't know if ADA does that or not.

[lgvincent]

I would appeal. I think a lot of these insurance companies just deny things like that to save themselves some money in the short-term. I'd encourage you to become a pain in their butt until you get it. It might not work but it will be to your benefit if it does. How much does the proceedure cost? (If you don't mind my asking.)

[Hammer]

I'd appeal. It might not get you anywhere, but you never know. I've hated Blue Cross and Blue Shield for many years because their mindset seems to be to deny anything and everything with the hopes that you'll go away. I argued with them on almost every medical bill I've ever had. They've even come back a year later after paying for an MRI and saying that they were going to sue the hospital to get back the money they paid because to them the MRI looked like it might have been needed because of some sort of accident and should have been filed under a workman's comp case. I don't know who the idiot was who came up with that garbage, but I called them to cuss them out and was told that was normal procedure and that no action was going to be taken against the hospital. (the bill was legitimate, and I have never had an accident of any sort.) The fact that it was their "normal procedure" is what angered me. They sent that letter to everyone who had an MRI.

BCBS is in my opinion, nothing more that a bunch of scam artists trying to rip you off for every dollar they can get. I was so glad when my company finally got rid of them and got someone else....anyone else. If you want to argue get BCBS.

[xMenace]

Appeal. Document your improvements including lowered A1C and hypo events.

I highly suspect they put up roadblocks knowing most won't press.

[gettingby]

Thanks for the replies so far.
Frank, you are right. They cover blood work and other tests/x-rays without any problem. My endo said this was medically necessary so I'm going back to him to get his help with the appeal.
Lowell, it only cost $160. Considering how much we pay them weekly for insurance ($176/week), it shouldn't and wouldn't hurt them to pay the danged $160.

[RobiJo]

Go for it. What's the worst that could happen...they tell you no?

[Scrabblechick]

Like RobiJo said: the worst they can say is "No." And John's right. Keep track of your improvements, and also get your doc to write a letter of medical necessity. Go for it! And good luck!

[Dewey]

I'm with Frank, LG & whoever else said to appeal. I also agree with Frank on insurance covering other "investigational" procedures.

You could do like I did & get the state insurance commissioner on their butts. If one were to sue an insurance company, the company could hide behind loopholes & a settlement might be a little blip on their radar. However, if the company doesn't go by what the state commissioner enforces, they get fined (sometimes, daily or weekly) until the company does right by the insured patient.

Don't allow them to Not cover you for something like this...I don't care how little the procedure cost. You could just say (like Carwy did when insurance wound up having to cover my CGMS), "There goes a bottle of champagne for the CEO."

[gettingby]

LOL, Dew. Glad to see you back.
I'm planning on appealing. Got the ball rolling by calling my endo's office and am waiting on a return call from them. It's like hubby says, we pay them so much each week that this little amount won't hurt them.

[davef]

Cin,

Definitely appeal, as Frank pointed out this is no different to having an MRI, Blood Test etc, in a way it's very like a blood test. I would ask your Endo for any supporting documents he will give you, especially if he would write a letter stating that it was a test performed at his request in conjunction with other tests (A1c etc) to be used for diagnostic, treatment purposes.

Hopefully the insurance can see past "the book" and operate on the basis of logic, which is something that does come naturally to them.

[Funnygrl]

Yes, you absolutely should appeal. Appeals work! There's no reason you should be stuck with the cost. Since you only had it for 72 hrs, it should not be hard to get them to pay.

[UpNorth]

I really think you should appeal! There's a reason your Endo wants you to have this done. And you're paying a heck load to that insurance company, so then they should help you when you ask for it!