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Tony

Appealing the cgms

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Tony
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.

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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.

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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.

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KickStart101
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. :rolleyes:

 

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.

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BlueSky
.... 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.

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JediSkipdogg
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.

 

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.

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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

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JediSkipdogg
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.

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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.

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camjen1

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?

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BlueSky
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. :o

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Dewey
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.

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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.

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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.

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BlueSky
.... 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. :o

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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.

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JediSkipdogg
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.

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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.

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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 heck 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.

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camjen1
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. :o

 

 

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.

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NoelD
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. :o

 

I was on Lantus and Apidra and switched to the pump with apidra.

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Dewey
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 "poor man's pump" for nothing. :o

Ummm, no. I was on Ultralente, Not NPH. While I had used NPH in the past, I was not on it the entire time prior to pump therapy. I had been using Ultralente for quite some time prior to pump therapy, and still was unable to achieve satisfactory A1Cs. Ultralente basically had the same attributes of Lantus or Levemir, in that it was a steady basal insulin.

 

Personally, I have absolutely No interest in trying Levemir or Lantus, or going back to MDIs. I've heard that Lantus can pool under the skin (which can cause absorption issues or cause a lack of proper absorption), and I'm not a big fan of putting yet more types of insulin into my body that contain that "wonderful" m-cresol (preservative). I have no qualms in taking shots or even doing the "untethered" regimen if & when needed (provided I can use Ultralente, not other types of long-acting), but since I've been doing quite well on the pump & have been able to achieve excellent A1Cs, why ruin a good thing!?

 

We need to realize that not everyone can be controlled via shots & shots alone. I'm just one of many who are "living proof" of that.

 

Tony, sorry if I distracted from your thread in any way, and I sure hope you get the coverage needed for your CGMS. Please continue to keep us posted on your progress regarding the MM CGMS. Your fight may help others who have problems getting theirs covered.

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cat_collector

I have been working with my ins company since late April just trying to get a yes or no . Finally this week I got a supervisor that was a bit ticked that have been not geting back to me and dragging this out . I should have my answer Mon or Tue and I feel confident that they will cover it . It old her i was ready to just give up and she told me to NOT do that so if it is NO i will appeal it .

 

I have not been able to find a price on these can anyone give me an idea ?

 

Tracy

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JediSkipdogg
I have been working with my ins company since late April just trying to get a yes or no . Finally this week I got a supervisor that was a bit ticked that have been not geting back to me and dragging this out . I should have my answer Mon or Tue and I feel confident that they will cover it . It old her i was ready to just give up and she told me to NOT do that so if it is NO i will appeal it .

 

I have not been able to find a price on these can anyone give me an idea ?

 

Tracy

 

The MM system is roughly $1400. The Dexcom is $800. The new Dexcom Seven (not available for purchase as it was just FDA approved a few weeks ago is $1300. The sensors are $35 for days wear foir both the MM and the original Dexcom and $60 for the Dexcom Seven.

 

Now, some may say those prices are different, however, those are the prices insurance companies MUST go by.

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cat_collector

My CGMS was aprroved ! it only took since April but Im glad they finally got with it . I got a call from minimed and my Nurse case worker at my Ins co. They called my mail order Pharmacy to see if they would process it so I would have no co pay . Now I just wait bcs the sensors are on back order .If any one really wants this they should push there ins company sometimes it just takes persistance to get things done .

 

Tracy

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