My secondary has denied coverage for my CGM (Dex7) so I’ve started the process of appeal. I wanted to share a few resources that I have found helpful.
I’ve just started…this may be a long road.
The link below provide easy to understand steps on winning the appeals process. The attached file provides scientific evidence on the benefit of CGM.
Wish me luck!!!
How to Win Health Insurance Appeals
4665-Continuous_Glucose_Monitoring_Reference_List.pdf (83.9 KB)
Step 1: I am currently on the phone (on hold, of course) with federal BCBS asking for thier “internal clinical criteria” for approving a CGM. The rep has to keep putting me on hold and asking her supervisor.
In an earlier phone call she indicated one of the criteria was “a pattern of BGs of 50 and below”. Today she is telling me that the criteria is “individualized for each patient”. WHAT?! I replied that it sounds like they would be able to simply move the carrot to their advantage.
The conversation is still very pleasant. I’ve even thrown in a few compliments (can’t hurt, right?) But by now she must realize that I’m in this to win. The information provided by the Oley Foundation indicates that most insurance companies are required by law to provide this information. I asked if that wasn’t the case. (In my best innocent question type of voice)
Again, this has just started. Wish me luck.
Here is how today’s battle ended. I was on hold for a very lllllloooooooooooonnnnnnnggggg time with the insurance rep. (I’ve decided putting someone on hold is thier form of punishment). She had contacted someone in “correspondence” who was “drafting” information on the internal clinical criteria. She would put me on hold and come back to check on me and tell me this lady was drafting the information. I really think she was just hoping I would hang up.
During one session of “checking on me” she said she wasn’t sure if the lady would get the letter drafted today. I said that even if she did get it done surely the rep just wasn’t going to read it to me over the phone…correct? I finally ended the call by saying that if I didn’t get the letter in a few days I would just call back. (All was said in an almost too “chipper” of a voice) Remember, this is the first day…I doubt I can stay “chipper” for long.
I was recently in this process myself. The initial CGM authorization was for one year, which came up and I had to get a new authorization. They asked for one month of logs, and denied on the grounds that my lows were not bad enough to warrant a CGM. I then went through my year’s worth of data to put together further proof of lows, especially ones at night. They generally also seem to want an indication that you needed assistance because of your lows. I told them that my partner has had to wake me up so that I can treat my lows. I also talked several times with Dexcom reps and saw my endo during that time to help gather more support. They did end up renewing the authorization.
What I find troubling is that once you prove that the Dexcom can provide great blood sugar readings most of the time, they think it’s no longer needed. Somehow the insurance companies miss the point that this device is the reason why I can have such good control now. My a1c was around 6.5-7 when I started, and has continued to be lower each time I check, down to 5.3% recently.
Brenda –
I see you are on BCBS Federal. We were denied last year on BCBS Illinois. Their website also lists Federal on it, but I’m not quite sure how all that works. Anyway, I don’t know why they are so secretive on the phone about what makes cgms medically necessary. Here’s what the BCBS of IL website says:
Personal continuous glucose (long-term) monitoring (CGM) in interstitial fluid, including real-time monitoring, as a technique of diabetic monitoring, may be considered medically necessary in patients with Type I insulin dependent diabetes (including pregnant women) who have been previously monitored with a professional (intermittent 72 hour) glucose monitor, AND have been compliant with a regimen that includes: * four or more finger sticks each day, AND three or more insulin injections per day; OR * use of an insulin pump;AND have not achieved adequate metabolic control as evidenced by
- frequent nocturnal hypoglycemia, less than 50 mg/dL; OR
- wide fluctuations in blood sugar patterns over time (<50 mg/dL, or >150 mg/dL); OR
- discordant hemoglobin A1c (HbA1c) and fingerstick blood glucose levels (i.e., patient with consistent normal blood glucose levels at home but high HbA1C levels).
Other uses of continuous monitoring of glucose levels in interstitial fluid, including real-time monitoring, as a technique of diabetic monitoring, is considered experimental, investigational and unproven.
You might want to check and see what the ICD9 code they are using for your cgms claim. Some codes are more likely to get approved.
I am also embarking on a BCBS appeal. Last year they flat out denied anyone under the age of 25, so we paid out of pocket for a new transmitter and sensors. They revised their policy on January 1, 2011, so I’m hoping we can get reimbursed. Since we too were already on cgms I would hope they use some common sense and throw out their rule for 72 hours of Ipro.
Hope that helps. Good luck with your appeal.
Thanks MidwestMommy, your info is indeed helpful. I’m not sure how the BCBS federal works either. This claim was processed by Utah BCBS. State BCBS must contract with federal govt., but not all our claims are handled by Utah. Go figure.
What is a ICD9 code?
Good luck with this Brenda!!! You have more optimism and courage than I do. My new health insurance says they have never insured a CGM. Since I started with them Jan 1, I am hesitant to rock the boat so soon. They are covering my pump and all supplies, and so many meds and other things. My former employer pays my premiums. I have a good deal even without my Dexcom. I do miss it very much, but I just feel funny plowing into an appeals process at this time. I think all this is just a way of saying I am chicken. LOL!
Richard, I fully understand where you are coming from!! Not chicken…maybe just wise. I’ve made it my goal to stay upbeat and ALWAYS be polite and civil. (I typically am, but this may test even the best of intentions and attitudes!)
Brenda, I believe this is the policy for Utah BCBS (also referred to as Regence?) The blues are so confusing!
POLICY/CRITERIA 1. Continuous monitoring of glucose levels in interstitial fluid as a technique of diabetic monitoring, including real-time monitoring, may be considered medically necessary when the following criteria (A, B, and C) are met:
The patient has diabetes requiring treatment with insulin; and
The patient uses best practices, including compliance with a regimen including 4 or more blood glucose tests (“fingersticks”) per day and adjustment of insulin; and
One of the following 2 criteria are met:
The patient is pregnant, or
The patient has documented recurrent unexplained severe symptomatic hypoglycemia that puts the patient or others at risk. Severe symptomatic hypoglycemia is generally associated with blood glucose levels less than 50 mg/dl.
Other uses of continuous monitoring of glucose levels in interstitial fluid in patients with diabetes, including real-time monitoring, are considered not medically necessary. Uses in conditions other than diabetes are considered investigational.
It’s a pretty tight policy, you have to have multiple lows under 50 for cgms to be medically necessary.
I hope you can fight it and win - it is such a valuable tool. Keep us in the loop!
Here is the link:
I’m glad that you posted this discussion. I posted one today on the Dexcom users board too, Excellus BC/BS has denied my CGM saying it is not medically necessary, after I have been on the CGM for 15 months! And after they told me and Dexcom that they would cover it. I will start the appeals process tomorrow.
Sue59, I am just now finding the time to sit down and write my initial appeal letter. I’ll try to share or post when I get it done. Why reinvent the wheel when we can cut and paste from others!!!
Brenda, I have my appeal letter done, and am waiting to get a copy from the hospital of the statement that shows I was treated for hypoglycemia in the ER in 2006. I will also send a Dexcom graph that shows blood sugars below 40, and the CoPilot report of my OmniPod blood sugars that shows 6 readings <50 in a two week period. I also called DexCom, and they will send the insurance more information from my endo.
I won’t give up without a fight.
Rule #1: Never Attempt to do anything by phone. Now matter how “high up” the Supervisor pretends to be, they are merely Customer Service, and cannot make the Medical Decision you desire. They can only quote “the Policy”.
With respect to a denial, the Company hopes to see you waste vast amounts of time and get nowhere. The only questions for CS must be as follows:
First one, “What is the mailing address for Appeal of this denial?”
Second one- “What level of Appeal will my request invoke, and when may I expect a written response”?
And third- “Does this kind of Appeal get only an administrative review, or will it get a response from one or more M.D.'s who claim competence in this field?”
Until a licensed MD has their career on the line, they’ve got you playing a silly game. They hope that you just give up, becoming tired of it BEFORE initiating a genuine appeal.
“BCBS” is an association of about 40 healthcare companies. Some are small, active in only a single Metro area or a few Counties within a single State. Some are non-profit, while many (such as the Godzilla of the BCBS companies, Wellpoint) make obscene profits and award their CEOs with multi-million compensation packages.
The confusion is intentional: WellPoint uses the “Anthem BCBS label” to hide their identity; and most of their Websites and Literature name another “shell” company as the “parent”.
I can destroy this “policy” with hardly any effort at all. But the letter which you’d have to send will be REALLY nasty and threatening to the decision maker. If that notion makes you smile, then send a “friend request”.
If you’re too gentle or sophisticated to consider using a sledge hammer to make your point, then I’m not your guy. But you have my wishes for success, either way!
No, no. You don’t have to meet their “tight policy” for it to be “medically necessary”. Their policy is completely arbitrary until they defend it, convincingly, on scientific medical grounds.
My letter (hint, hint) would attack their number: They dare to characterize bG of 51 as safe, not putting “the pt. or others at risk”. But in fact, there are plenty of accident records in which their so-called-moderate levels of hypoglycemia have been implicated as a primary cause.
There has been at least one study of reaction times for persons subjected to artificially induced hypoglycemia; speed of response by the participants was worsening rapidly at levels far above this value.
FAA Regulations also require an insulin-using PWD, acting as pilot-in-command (or other flightcrew member, to maintain a bG in excess of 100 throughout the flight (starting from 1/2 hour before takeoff). But This “Policy/Critera” Document requires that Policyholders live without CGMS, in situations where bG levels may fall to roughly half that value. This constitutes a danger to those persons, and in the case of falling bG while driving, to others as well.
If your “diabetes expert” MD has approved this “Policy”, which appears to considers a bG value of 60 mg/dL, or even 55 mg/dL to be without risk, then perhaps that person is in need of Remedial Education. Or other corrective action.
This is only a rough draft- DO NOT USE IT. I haven’t reviewed the typing I just did, The FAA stuff is probably too long. And the exact wording which you SHOULD use depends on your State of residence. Make me a friend, send me a message.
Brenda, I sent my letter with enclosures out yesterday, including your Continuous Glucose Monitoring Reference List, thanks for that. I would very much like to see your initial appeal letter, if you get the chance to share it.
Hello ALL, I finally received my CGM. I also have BC/BS and of course, they denied my first attempt. But once I learned the game and what the rules were for this game …I WON ! I had to send false readings to their approval board to show uncontrolled lows-and-highs to prove medicial necessity. Even though these BG reading were not entirely true, I was going to win this game, called, “Jumping through hoops.”
Don’t give up…the CGM is really cool. I can tell already, in this short time, that my BGs are better. I’m sure you will enjoy this great tool for us T1.
Look forward to hearing a successful story shortly !
Dude –
Did you actually read what you just posted? Not cool.
The official description is messy, but I’ll describe it as “Codes of Diagnosis, Version 9”. ICD-9-CM codes describe diseases, injuries, symptoms, and conditions. Medical services which are performed as treatment of those “conditions” are described by another set, the “CPT” codes. (Which I’ll describe as “Codes of Procedures and Treatments”). There’s a relationship, of course. Treatments are “proven safe and effective” for some conditions, while being nonsensical and inappropriate for others.
The diagnosis codes for most Diabetes conditions are “250.x”, in which “x” can be one OR TWO digits. There are exceptions- “secondary” diabetes (e.g., caused as a side effect of one or more drugs, or caused by treatment for Pancreatic cancer, and so on) fall into “249.x”; Gestational Diabetes falls is covered by code 648.8, and so on). Here’s a great summary page: http://icd9cm.chrisendres.com/index.php?action=child&recordid=1894
Within that page, the abbreviation “NOS” stands for “Not Otherwise Specified”.
I strongly, STRONGLY agree with MW-Mommy: This is not a game to be “won” with fraudulent lies. We “win” because the Facts, and the Law, are on our side.
This behavior was unethical. Please think about it.