A Medicare Appeal for CGM Coverage: One Patient’s Never-Ending Story. By Dan Patrick

This is a piece written by a friend to many of us, Dan Patrick, who has lived with diabetes for 50 years. He kindly asked that I share his efforts with our community. This really is such a battle for so many…

The author, who has lived with type 1 diabetes for more than 50 years, shares his account of a successful appeal of Medicare’s policy of refusing to pay for continuous glucose monitoring (CGM.)

See more at: http://www.ajmc.com/journals/evidence-based-diabetes-management/2016/May-2016/A-Medicare-Appeal-for-CGM-Coverage-One-Patients-Never-Ending-Story?


Thank you for posting this link. I am certain it will be helpful to many who are going through, or about to go through the appeals process.

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You are welcome! I hope it is helpful for some!:relaxed:

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Fight the good fight brother!


Thanks for this. I am going through the same thing now. They just want to kick us Medicare age people to the curb.


My theory is if they starve us of food and medical aid we will cost them less in pension. Have to admit I am somewhat cynical.


Hi All,

Suggestion, when you read the article, be sure to click on the pdf version. There are five Figures which are important to the article. One particular point. As a diabetic speaking to another diabetic, we have a sense of the vocabulary. This is a bad assumption to take when one starts an appeal process of Medicare. Assume nothing. Take the position that the person reading you appeal knows nothing about diabetes. Be clear in defining your needs. Meaning we need all the three components of a CGM. The sensors, the transmitter and the receiver. How long do you need this particular piece of equipment. Until a better model is available or until diabetes is cured! Figure 4 is a comparison which demonstrates the value of the equipment. The point of Figure 5 is to express the time spent in a Normal glucose range. Would any of your instructors consider a 40% grade as passing. After 50 years of a T1D, I am unaware of an approaching hypoglycemic event. This is the reason for the equipment!!

Hope this helps and as always have a great day,. Thanks Cynthia for posting the article.


Hi All,
AS a follow-up, I can report that I was successful in a re-evaluation of a denial of a transmitter order for my Dexcom G4 CGM. The denial started with the order in March 2016. After written notification of the denial, a Level 1 re-determination was started. What a set of games. One needs to stay on top of your appeal. The most interesting fact was my written notification of a formal Level 1 appeal. Contained within the appeal was a three page letter from my Endo. My Endo followed up with a phone call and a re-filing of the three page report and requested an expedited appeal. When you initiate an expedited appeal be sure that you are able to respond within the time frame. This is a difficult and time sensitive portion of the appeal process.
Hope this helps and as always have a great day. Oh, btw, remember to visit dpac and forward letters to your Federal House and Senate members.

Hi Dan. I went through the Medicare Appeals process many times for CGM coverage and was successful at the ALJ level almost every time. In my case however, the AdQic appealed to the MAC and the MAC always ruled in favor of the AdQic. The only choice I had left was to go to Federal Court at a cost of upwards of $30,000. In the end, that kind of money covers a lot of CGM supplies so I chose not to go further. It was a frustrating and difficult four years of fighting and disappointment. I was hoping to see HR 1427 and S 804 pass in Congress, but at this point it looks highly unlikely. Medicare is antiquated in its coverage of Type 1 Diabetes, and I truly believe it is because until now most T1D’s did not live until Medicare age.


WOW. I am just now starting the process. I’m not sure if i am smart enough to pull all that together. I feel so alone, yet I know there are others out there suffering the same outcome. Medicare denial for CGMS. Anyone willing to talk to me about this, please reply.

How did your appeal process go. I am trying to pull something together now.

I am finally getting my ALJ hearing the 9th of this month. I really don’t have much hope and have not invested much time in preparation. This will mostly likely be my last attempt to get coverage resumed. I wish congress would quit sitting on the coverage bills they have.

Support First Responders

That’s my concern, It seems like I have to fight for everything. I’m too
exhausted. Depression has a hold of me apparently. There will be better
days but sometimes it’s just too much. Don’t worry, I will gather another
head of steam tomorrow. I have been at my computer since 9:30 this morning.
Five and 1/2 hours. Time to stop and watch Ellen :smile:wishing you all the best
in your diabetes life and your appeal.

Had my ALJ hearing yesterday. Supposed to have an answer in 30 days or less. Not expecting much. The UHC rep just kept saying they didn’t deny my need for the CGM, but they didn’t have to cover it. The judge sounded a little surprised when I said they had covered me for two and a half years when they didn’t have to. And the rep could neither confirm or deny I had been covered because she hadn’t bothered to look at my records.

Keep us in the loop! The last thing I heard is that even when people win their appeals, UHC still hasn’t paid. Hopefully that has changed.

I’ll be on Medicare in the spring and have been working hard to figure out how to navigate it. There is one Cost plan (fairly unique to Minnesota and a hybrid of Supplemental and Advantage) in Minnesota that covers CGM, but it would charge me more for everything else. So it is not a savings over another plan that doesn’t cover CGM, but covers pump supplies and test strips at 100%.

I think it’s age discrimination. And discrimination against people with
disabilities! Though I don’t like to consider myself disabled. Wonder why
no one ever approaches it with that angle.

Hi All,

First, a Medicare Appeal Process is a challenge. Do NOT give up. My suggestions for a starting point is: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedicareAppealsProcess.pdf. This is the current directions as of November 25, 2016.

Consider this a game and our goal is to play to win. I understand that for some of you your feelings are important. But, by the time to hit the third level with an Administrative Law Judge it becomes a question of fact.
what do we need, why do we need the CGM? Can you prove it works?

Can you document your success? Having an Endo on your team helps. It is my understanding that some 30 individuals have received ALJ approvals. How, here is where the current fight exists. Should the fourth level, see the above referenced guide, is forwarded up to the Medicare Advisory Council, an approval at this level would by default define a positive answer - meaning a method for CGM approval. Cases forwarded up to the MAC are being forwarded back to the ALJ. The ALJ do not want to re-open closed cases. So, give your appeal the best fight possible. Reach out to individuals for help. You can do this and succeed!.

As always have a great day and blessings for the Holiday Season.


Here’s what I don’t understand.

Approving CGMs for T1s would seem to me to be a relatively inconsequential expense in the budget for overall Medicare spending. There just aren’t that many.

Or am I missing something in this analysis?

Here is where I am as of today.

What happened with your March letter from insurance denying coverage of the CGM even after your successful ALJ determination?

On behalf of my husband, we have been trying to get him a CGM for years. This year I finally made the big push, hounded and pressured the endocrinologist to help us, and am climbing the appellate mountain. Unlike you we don’t have comparative data from before and after use of a cgm because he has not been able to get one. Any suggestions as to how to prove it works? Is there anything specific that I should ask our physician to write? And to whom can I reach out for help?

We have also been active in the fight to get legislation through congress. Our representative was the sponsor for the bill in the 114th congress. Unfortunately, the sub-committee chair felt health is a partisan issue and wouldn’t let the bill go anywhere. He is retiring at the end of this year. He already closed his office so any communications to create some continuity into the next congress are lost. We will all have to begin the legislative process over again with the next congress. We need to find a way for diabetics to act with one voice, a loud voice, and get congress to act. In the meantime we fight individually for our own life and/or that of a loved one. Let’s help each other with any information we can.