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Tony

Appealing the cgms

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kgm0612

Congratulations Tracy.........I hope the sensors aren't on backorder too long!

 

I have an endo appointment today after work and I'm going to talk to him regarding the CGMS. I'm also curious to hear from him if there's any "new & improved" items expected out on the market in the near future.

 

Karen

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kgm0612

I saw the endo yesterday. He's going to write a letter of necessity for the CGMS but already warned me that United Healthcare has been denying them. I'm going to put in a call to United today and want to speak to an information specialist, not just a rep. My endo wants the name & address of the person he should address the letter to.

 

A1c was 6.8, down from 7.1 three months ago. My blood sugars throughout the day are pretty good.........it's a roller coaster ride after dinner though. I hate this disease!

 

Karen

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nab486

I have a question.... everytime I call BCBS they tell me Minimed has to call them... then I call Minimed and they say they can't call the insurance company .... am I not talking to the right people??? How do I get this ball rolling? I have already purchased the CGMS but would love to get the sensors covered.

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SPowell42

My insurance company has the same verbage. It has nothing to do with the old Guarding. The insurance companies are trying to argue that if you use a CGMS for 3 days, twice a year, you can learn enough trend info to maintain your diabetes without having CGMS continuously.

 

Just another way they are trying to weasel out of this.

 

Scott

 

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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dgrilli

Anyone have any information for the State of Pennsylvania and I have United Health Care.

 

Does Pennsylvania have similar laws?

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Funnygrl

 

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.

 

 

I have no idea what that ER visit included for $202 but I went to the ER for a hypo and my insurance paid $9000.

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kidvid
I saw the endo yesterday. He's going to write a letter of necessity for the CGMS but already warned me that United Healthcare has been denying them. I'm going to put in a call to United today and want to speak to an information specialist, not just a rep.

 

Karen

 

I'm on United Health Care in Colorado - I called last week and they told me CGM was covered. I'm starting the application process this week.

 

Good luck,

 

Joe

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kgm0612

Joe..........I have been waiting since July to hear something back from United Health. On Friday, I received a copy of a letter United sent to my endo requesting more patient information before a final decision is made.

 

I know this is going to sound strange...........A part of me wants the CGMS and a part of me is saying "wait". My thought is that within a short time a "new & improved" version will be out. So, if they decide to approve it now, I'll try it. If they don't, no big deal. I'll wait it out.

 

Karen

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someone
I know this is going to sound strange...........A part of me wants the CGMS and a part of me is saying "wait". My thought is that within a short time a "new & improved" version will be out. So, if they decide to approve it now, I'll try it. If they don't, no big deal. I'll wait it out.

 

The Minimed monitor just came out about 6 months ago and the Dexcom seven shortly after. Relatively speaking, these are pretty new. Unless the already long awaited Navigator comes out soon, I think it'll be a decent amount of time before Minimed or Dexcom come out with something new.

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JediSkipdogg
I know this is going to sound strange...........A part of me wants the CGMS and a part of me is saying "wait". My thought is that within a short time a "new & improved" version will be out. So, if they decide to approve it now, I'll try it. If they don't, no big deal. I'll wait it out.

 

The Minimed monitor just came out about 6 months ago and the Dexcom seven shortly after. Relatively speaking, these are pretty new. Unless the already long awaited Navigator comes out soon, I think it'll be a decent amount of time before Minimed or Dexcom come out with something new.

 

I'm in that same boat. However, MM is coming out with something new shortly. I can't recall if they are still in FDA approval but they are going for a longer sensor wear as well. To the average person that may not seem like a huge benefit to wait, but in my opinion it might be. At least if you have say a 5 day wear MM and it last 2 days all the time you can call the company up and complain. Where if you have a 3 day unit and they only last 2 days they will say that's good enough of a life. While it may just be a small software change to do that, I think it's huge enough that some should wait.

 

Now if one is waiting for another company to come out with one, I'd say it'll be a while. And someone, FYI...the MM Guardian RT came out in December but the unit prior to that was out a few years before that (the one that just gave numbers on the display, no graphs.)

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someone
And someone, FYI...the MM Guardian RT came out in December but the unit prior to that was out a few years before that (the one that just gave numbers on the display, no graphs.)

 

http://www.diabetesforums.com/forum/pumping-insulin/17052-minilink-real-time-transmitter.html

 

It came out on 3/12 and I bought mine on 3/20. As far as I'm aware, the current stand alone RT was not sold prior to the release of the Minilink transmitter.

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JediSkipdogg
http://www.diabetesforums.com/forum/pumping-insulin/17052-minilink-real-time-transmitter.html

 

It came out on 3/12 and I bought mine on 3/20. As far as I'm aware, the current stand alone RT was not sold prior to the release of the Minilink transmitter.

 

That's the smaller version of the transmitter. The CGMS pump system came out last summer and then the Guardian RT (that looks like the pump came out in December 2006. Before the Minilink the transmitter was this (which was non rechargeable, non battery replaceable, and lasted about 9-12 months)....

 

guardian_real_time_cgms_2.jpg

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someone
That's the smaller version of the transmitter. The CGMS pump system came out last summer and then the Guardian RT (that looks like the pump came out in December 2006. Before the Minilink the transmitter was this (which was non rechargeable, non battery replaceable, and lasted about 9-12 months)....

 

guardian_real_time_cgms_2.jpg

 

Ok then.. I stand corrected. I didn't know the pump looking receiver was ever available with the original transmitter.

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Alaska

My insurance has denied paying any of my pump supplies since I got the pump. They paid for the pump but not the supplies which I thought odd. So since I just FOUND this sticky I thought I'd look up Alaska state laws which reads as follows

 

Sec. 21.42.390. Coverage for treatment of diabetes.

 

(a) A health care insurer that offers in this state a health care insurance plan that includes coverage for pharmacy services shall initially and at each renewal provide coverage for the cost of treating diabetes, including medication, equipment, and supplies. All health care insurance plans must include coverage for outpatient self-management training or education, and medical nutrition therapy, if diabetes treatment is prescribed by a health care provider. The coverage required by this section is subject to standard policy provisions applicable to other benefits, including deductible or copayment provisions. Coverage for the cost of diabetes outpatient self-management training or education and for the cost of medical nutrition therapy is only required if provided by a health care provider with training in the treatment of diabetes.

 

SOOOOOOOOOOOOO......these jerks owe me some money. I've written the state insurance division and I'm contacting my lawyer the first of next week to get him on this. Chaps my butt........lol

 

Tony........I owe you a HUGE thank you for showing me the light

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palefacegirl03
My insurance has denied paying any of my pump supplies since I got the pump. They paid for the pump but not the supplies which I thought odd. So since I just FOUND this sticky I thought I'd look up Alaska state laws which reads as follows

 

Sec. 21.42.390. Coverage for treatment of diabetes.

 

(a) A health care insurer that offers in this state a health care insurance plan that includes coverage for pharmacy services shall initially and at each renewal provide coverage for the cost of treating diabetes, including medication, equipment, and supplies. All health care insurance plans must include coverage for outpatient self-management training or education, and medical nutrition therapy, if diabetes treatment is prescribed by a health care provider. The coverage required by this section is subject to standard policy provisions applicable to other benefits, including deductible or copayment provisions. Coverage for the cost of diabetes outpatient self-management training or education and for the cost of medical nutrition therapy is only required if provided by a health care provider with training in the treatment of diabetes.

 

SOOOOOOOOOOOOO......these jerks owe me some money. I've written the state insurance division and I'm contacting my lawyer the first of next week to get him on this. Chaps my butt........lol

 

Tony........I owe you a HUGE thank you for showing me the light

 

 

I hope it works out, it is stupid to cover one thing and then not cover something else. If they covered the pump then they need to cover the supplies, it is that simple.

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modbom

I just got approved by Oxford. Here's what minimed suggested I do with regards to my insurance company:

 

The first step when trying to get coverage on the Paradigm Real Time Continuous Glucose monitor is to ask for a single case negotiation. Get a case number, pre determination number, or pre certification number (different insurance companies call it different things) from an insurance company. It’s best to speak with a case manager, not the customer service rep that answers initial call. The patient should know what they are asking for so they should read the attachments prior to making the initial call.

 

Some questions that may be asked:

 

1. Diagnosis code-250.03 (this code is considered uncontrolled type 1 diabetes) 250.01 is type 1 diabetes- Juvenile Diabetes. You may ask you health care provider what your diagnosis code is.

 

 

2. Description and cost of item

 

Paradigm Real Time Continuous Glucose Monitor $999

Monthly ongoing cost of sensors $350

Code- this is where it gets tricky. We use a miscellaneous code to bill for this since it's such a new product for us. The code we use is E1399.

 

3. Date of Service- depends on availability. It’s safe to say one month after the conversation with the insurance company takes place.

 

4. Manufacturer information

Medtronic Minimed

18000 Devonshire Street

Northridge, CA 91325

phone- 800.933.3322

tax id- 954662001

 

5. If the insurance company says you do not need a case number or pre determination because it is a covered item, talk with someone else.

 

 

It’s usually a good idea to speak with a case manager that has a medical background. You will want to make sure they do not think you are asking for coverage for an insulin pump or a glucometer. They need to know this is a new device that has only been available since May 2006.

 

VERY IMPORTANT- Once you speak with a case manager, let them know your doctor would like to send in supporting documentation. Please get the fax number used to send in supporting documentation, case manager name, phone number, and extension. At that point in time, I usually work with the patient to get relevant health information to put together a letter. I email the letter to the educator, social worker, or doctor and they fax either to the patient or to the insurance company directly. If it goes to the patient I ask them to include blood sugar logs, the guard control trial, and hcp product description.

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KEVIN88GT

funny that I found this thread.... I'm currently fighting with HIP healthplan of New York to approve the Minimed CBGM...

 

they denied me when I asked for it so I sent a letter to their Grievance and Appeal Dept (along with letter of medical necessity from my Endo and a letter from my stating I ended up in the ER from a hypoglycemic seizure resulting from hypounawarenes)

 

I called them up to find out the status and they said it was denied... I should be getting the official letter as to why shortly and will post what they said...

 

the lady on the phone basically summed it up as... They say they'll cover it for a one time use for like 10 days... so you could get your patterns and be done with it.... are they nuts? I had a hypoglycemic seizure because of hypounawarenes and I need thing thing ALL the time to make sure I dont bottom out at night..... what are these people smoking? The nurse from the DME dept actually said

 

"Why do you need to know what your sugar is every minute?"

 

I said "Would you rather me do 30 fingersticks per day?" I'm an RN myself...and found her to be a total moron...

 

I'll wait for the letter and post what they said here.... in the meantime my Endo is going to have me try the system for the 10 days that they DO cover it for....

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kgm0612

I first started my quest for the CGMS back in July. United Healthcare has "misplaced" my paper work 2 times and keeps requesting more info from my endo. Last month, I threw in the towel. I've been pumping 2 years and have another two years left before I can get a new pump. By then, I'm figuring something "new & improved" will be out on the market. I've gone 5 years without a CGMS, what's another 2 years! LOL

 

Karen

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JediSkipdogg
I first started my quest for the CGMS back in July. United Healthcare has "misplaced" my paper work 2 times and keeps requesting more info from my endo. Last month, I threw in the towel. I've been pumping 2 years and have another two years left before I can get a new pump. By then, I'm figuring something "new & improved" will be out on the market. I've gone 5 years without a CGMS, what's another 2 years! LOL

 

Karen

 

I actually took that same exact method. Why waste all my time fighting and then possibly have to fight if something better comes out next year. I would have even a harder time fighting then. I know the flaws with the current CGM technology, so in my opinion waiting is the best option. I've gone 25 years without it, what's a few more?

 

Twice now I think my doc's office has messed up. The first time they kept arguing with me that I needed to see the nurse educators first. And due to work I had to keep changing appointments and finally gave up on that. Then this second time I saw the educator, wasted an hour of my time, walked out and knew nothing more than before I went in, and still dont' have a CGM. I gave them all the appeal paperwork for the insurance company and haven't heard back from them so I'm assuming the doc's office never sent it in, and now the appeal time has expired.

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morrisma

For dgrilli and any other PA cgms questers:

 

State of PA House Resolution No 197 of 2005 was the most recent but is not a requirement only a 'support of efforts'. HB 656 of 1998 is more comprehensive in that it required coverage for diabetes supplies.

 

Here's the link:

HOUSE BILL 656 P.N. 2505

 

Good luck,

Mike

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jky400e

Karen,

I started my quest in October of last year. At that time the approval process was different and it sounds as though you are using that old process for approval.

 

I did out of pocket and then went for approval. It was backwards but it did work.

Currently the process or it was a few months ago is it is in MM hands just about 100%. United Health Care is one of the few that approves.

At the time I upgraded my pump with the trade in process, one year before a new one. And that is this next month.

 

I had a coworker that i showed the cgms to and he was approved and on cgms in 45 days. Long before i was so i just had to complain more.

 

The prescription from the doctor downloaded from MM

MM starts the process with UHC. The preauthorize

MM Then requested a copy of patient notes from my doctor and then sends to the person at UHC processing it.

Which that took just about 30 days, I think they lost it also. They have to dig and they were able to find each time i called and what went with it.

 

It took a long time to get reimbursed but i did.

 

I spoke to one person at UHC that deals with MM daily for this process. More of it is in MM hands.

 

Joe

T1 30 years

Pumping 24 years

CGMS march 2007

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