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Tony

Appealing the cgms

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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.

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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..

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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:

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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.

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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

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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;

© 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;

© 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.

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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.

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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

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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,

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someone

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

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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

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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.

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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.

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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:

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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. :)

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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!

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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

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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..

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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

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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.

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