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Tony

Appealing the cgms

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scratch101

Hrmn, seems I'm in this boat with y'all as well. Got approval a few months back for my CGMS (minimed, hooked up to my Paradigm 522) and everything was looking good, had my first 30 pack (3x 10) sets of sensors, and when I was finally getting near to ordering another supply from the 'distributor' I get a call from them telling me the supplies are no longer covered by my health insurance Empire BC/BS (for NY State employees). So I have a call in to them to see why they would approve the system/transmitter, but now not the sensors or the occlusive dressings.

 

Let the fun begin. :mad:

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KEVIN88GT
Hrmn, seems I'm in this boat with y'all as well. Got approval a few months back for my CGMS (minimed, hooked up to my Paradigm 522) and everything was looking good, had my first 30 pack (3x 10) sets of sensors, and when I was finally getting near to ordering another supply from the 'distributor' I get a call from them telling me the supplies are no longer covered by my health insurance Empire BC/BS (for NY State employees). So I have a call in to them to see why they would approve the system/transmitter, but now not the sensors or the occlusive dressings.

 

Let the fun begin. :mad:

 

Cuz they want YOU to pay for it.... FIGHT THE POWER! (My insurance HIP in new york also covers it for like a 10 day try... as if thats going to help me, I will try it for 10 days see how it works for me... if the readings are accurate I'm taking them to court)

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KEVIN88GT

guys I'm probably going to end up going to court through the state (New York) for a hearing regarding HIP Insurance denial the CBGM. I need to be prepared to do battle. What literature out there is there that shows the efficaccy of CBGM. I need things to show during the hearing when my insurance states "It's not a medical necessity"

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JediSkipdogg
guys I'm probably going to end up going to court through the state (New York) for a hearing regarding HIP Insurance denial the CBGM. I need to be prepared to do battle. What literature out there is there that shows the efficaccy of CBGM. I need things to show during the hearing when my insurance states "It's not a medical necessity"

 

There isn't much research yet which is why the insurance companies have such a great foot to stand on. Currently there is only the Star 1 and Star 2 trials conducted by Minimed. Finding the results of those two study trials should be in some medical journals out there. That's about the only research to date and it's not really 100% effective research because it has people on MDI compared to people with pumps and CGMS combined. Which pumping alone can offer a significant improvement.

 

The Star 2 trials (estimated completion in 2010) will compare MDI users to pump users to CGMS users to pump & CGMS users. It's the only study being conducted on a widescale basis to show the true effectiveness of CGMS and pumping. I feel once that study is out (unfortunately gotta wait the time) then insurance will gladly pick up CGMS without question.

 

Sorry I can't be more help, but right now there is little research showing how great CGMS is. It's all a personal word of mouth and it varies at how much it can save insurance (if any.)

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Doug

I applied for a Navigator here in Texas and as shocked when Abbott called 6 hours after I had given my nurse some final info to tell me that the Navigator was approved. I knew that there was NO way it happened that quick. I have UHC ins and had just had a new pump approved - After calling a few times I found that the "nurse" had called UHC and gotten the Prior authorization Number from the Pump and gave that to Abbott.

 

I called Abbottt back and told them to double check - sure enough The Young lady at the Drs office was wrong. In further research I found that she isnt a nurse but a "Medical Assistant" the dr cant afford to pay nurses on what the Ins pays.

So now Im starting back at square one - waiting for the paperwork to go thru and get considered for approval

 

With regard to the use of medical assistants - the fact that the Schools that train "medical assistants" advertise during Jerry Springer makes me nervous

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Pumped

For anyone interested here's my experience/journey so far - I have a Minimed 715 and am trying to get coverage for the CGMS portion of the 722.

 

I'm part of Blue Cross Blue Shield North Carolg to BCBS.

Also, I'm working with my employer to try toina (BCBSNC) Medtronic faxed over a prior authorization request, which was basically a letter from my doctor talking about why the CGMS was good for me, to BCBSNC. Got a denial letter 2 days later. Now I'm drafting an appeal letter which I'll be sending directly to BCBS.

 

A second front of attack is trying to change my company's insurance plan coverage. My company has a self-funded insurance plan and they get to tell the insurance co. what to cover by making changes to the plan. I'm praying hard that they'll be able to do something.

 

Of course, I'll be sure to post updates here.

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Kendall

I just recently got a new MM 722 pump and want to get CGMS. I tried and was denied. No big surprise there. I am planning on getting pregnant in the next several months and definitely want CGMS for that whole process.

 

I need to write the appeal letter and am wondering what to say. I will obviously tell them about pregnancy complications with high BGs. My biggest problem is that I am pretty well controlled and don't have hypo unawareness or nocturnal hypos. My last A1c was 7.4 before I was trying to get it down. I think my next A1c in two weeks will be much better. Should I show them the 7.4 or the new one. I think the 7.4 holds more weight along with the pregnancy plans.

 

Any suggestions??? I have looked at the children with DIABETES page and will round up the info they suggest. I'm really looking for what to put in the actual letter. Thanks!

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Doug

Follow up - Im on a Self Funded UHC plan in Texas and they just approved the Navigator

 

Im supposed to get it next week

The letter UHC sent me said I was approved for use from a dat in August to a date in November - So no commitment for future sensors but Ill cross that bridge later

 

ill try to assemble as much of the information as I can on the process and pictures of the delivery etc and put it on a web page somewhere in the next few weeks

 

FYI - since our Insurance is self funded and is delevered by UHC the approval process for me MAY not apply to others

 

Also finally I sent a cookie bouquet to the Drs office to thank the ladies who helped with all the calls and paperwork

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Doug

Well Navigator is here - it comes in a HUGE box - Ill post pictures later - After seeing the retail prices posted on the web IIm SHOCKED at the price my distributor charged - $650 for a box of 6 sensors ? :eek: and $875 each for the receiver and transmitter ( they come in one box ) - Total of of $3700 for the system and 3 months of sensors -- which is a shock compared with Abbotts quoted prices

The prices may vary depending on the distributor.

The system kit containing the durables including the receiver and

transmitter is generally priced between $960 and $1040.

The sensor kit containing a month’s supply of sensors (6 each) is

generally priced between $360 and $390.

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someone
Well Navigator is here - it comes in a HUGE box - Ill post pictures later - After seeing the retail prices posted on the web IIm SHOCKED at the price my distributor charged - $650 for a box of 6 sensors ? :eek: and $875 each for the receiver and transmitter ( they come in one box ) - Total of of $3700 for the system and 3 months of sensors -- which is a shock compared with Abbotts quoted prices

 

How do you figure 3 months of sensors? Are you really expecting 15 days out of each one? I know some have been fine with this, but for me, more than 6 days with the mm sensors is a no go...

 

It sounds to me like the $650 could be an error. I pay ~$400 for a box of 10 MM sensors so your Abbott quote sounds more accurate.

 

What ever happened to insurance covering it?

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Doug

3 boxes of 6 sensors each 5 days per sensor

 

5x6x3 = 90

 

$650x3 = $1950

 

The prices were on the invoice in the box. Insurance will cover it but that doesnt change the fact that its priced WAY over retail - helps me understand why medical costs are so high

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iPump
3 boxes of 6 sensors each 5 days per sensor

 

5x6x3 = 90

 

$650x3 = $1950

 

The prices were on the invoice in the box. Insurance will cover it but that doesnt change the fact that its priced WAY over retail - helps me understand why medical costs are so high

 

Billed amount has nothing to do with reimburst amount (what your insurance will pay). Even though they may be billing $650 per box the approved amount will be much less, and that is what your ins company will pay. Its the same with every doctor or hopital bill. the write off is called "contractual allowence".

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Doug
Billed amount has nothing to do with reimburst amount (what your insurance will pay). Even though they may be billing $650 per box the approved amount will be much less, and that is what your ins company will pay. Its the same with every doctor or hopital bill. the write off is called "contractual allowence".

After 20 years of bills, I understand that

 

My point is that it DOES make a difference what the billed cost is. The companies do that for some competitive or tax reason. Not everyone is under contract. It adds to the sky high costs of medical care.

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cwathne

after EIGHT months of fighting and two flat out denials from my insurance company I have finally been approved for the Dexcom CGMS!!!

 

I'm sooo happy that I wont have to keep paying out of pocket

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Dalia

That is fine. Congratulations.

I bought my Guardian RT for my own money and will continue buying sensors. My insurance is not covering price for these equipments.

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GrammaBear

I applied to Dexcom last July 13th for their CGMS, and Dexcom approved my application. Now a year later because I've changed Doctors, I have to go through the application process all over again. Somehow I don't think this is fair. I wonder if anyone else has had to do this?

 

It is bad enough that Medicare is forcing me to give up my OmniPod, but now Dexcom is requiring me to go through the application process all over again. And this application is just for the privilege of being able to pay out of pocket $350 per month. It is enough to make me cry

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doramider7
I don't know, I only researched the states.

 

Type 1 diagnosed in 2003. Experience with MDI, Guardian RT, Dexcom Seven Plus, Animas 1250, Animas 2020. Currently using Minimed Paradigm 722 w/CGMS.

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strutkitty

yep i'm in North Dakota we get NOTHING! and i'm UNINSURED and low income (SSD)...it makes this a WHOLE LOT HARDER i can tell you!

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