First as an early recipient the start of the 2016 year was goofy to say the least. What I did do
was to quickly start the appeal process all over again. It was written as a Level 1 Appeal. I reminded the health care provider and supplied copies of the Administrative Law Judge ruling. The health care provider agreed to cover the transmitter and the rest of 2016 has proceeded in a normal manner.
The first question is who are you filing an appeal with? Is is Medicare directly or do you have a Medicare Advantage Plan? Go on the internet and print a copy of the most recent Medicare Parts A & B Appeals Process. Follow the steps and use the specific language!
Who denied the coverage? A second key step; do not re-appeal with the health care provider. Go right to a formal Level 1 appeal and address the letter as such. Again follow the Medicare Appeals Process.
Here is one thought. Asl the Endo to request a professional ability to “try” a CGM unit. Two weeks of data is better than nothing. This way you can try one out and have two weeks of data. Be sure that the Endo and you get copies of the reports. Never send originals for any appeal. When forwarding your letters, send them in a manner that they need to be sign by the firm receiving the letter.
This will take time. Say the course and be sure to respond to the results of each letter. May you and yours be blessed with a joyful holiday season and a very Merry Christmas.
It is important to do a research into the Medicare system and pull and print a copy of A52464.
(A9276-A9278) are billing codes for the sensors, transmitters and the receivers. Billing codes
have nothing to do with medical information.
What is durable medical equipment? Be sue that when you read the link to the AJMC
article, on page 3 is an arrow to the pdf. What you will find is a copy of the actual magazine
article. Take a good look at the figures.
This is how your Endo can help. There is very specific medical language that you need to
use when preparing both your letter and the Endo’s letter. Meaning it is a medical necessity.
My husband has a Medicare Advantage Plan. We are at level 3 of the appeals process and have a hearing before an administrative law judge in a couple of weeks. I have done a lot of research which is how I found you and have copies of the A52464 and the LCD on which the denials were based.
Working with our endocrinologist is like pulling teeth. She finally wrote a one paragraph letter which at least states medical necessity. I am still working on getting more explanation out of her. Is there anything your endo. wrote that could help me guide ours? Is there a way to private message me?
What issue(s) did the ALJ address for your hearing? I am trying to frame the issues in a way that allows the judge to look at the Whitcomb case, pending legislation and accepted medical standard of practice. Basically, I am trying to frame the issue other than “whether the contract coverage provisions have been met.”
Where did you find information that some 30 people have been successful? Is there a way to communicate with them or find the ALJ’s findings?
I wish you the best in your ALJ hearing. I had mine about a month ago. The ruling for me was that no matter how beneficial the CGM is, and with graphs I provided from Dexcom clarity, and letters from my PCP and endocrinologist, the law said UHC did not have to cover me and his hands were basically tied. I really hope you have success.
You still have the opportunity to forward information to the ALJ of factors important to your case. Send them in a manner that you can track the delivery date. Be sure to give the ALJ sufficient time to review your information,. Now, in general terms, assume that the judge knows nothing about diabetes. There is a short video on the Dexcom site which explains what a CGM does and how it works. Be sure that you list and ask for all the component parts necessary for a functioning CGM system as part of the appeal. Further, your personal feelings are important. The ALJ has to have facts and documentation to support your appeal. My endo was on the phone during my appeal with the ALJ. Now, what can you document that will demonstrate to the Judge that you are during everything that you can and in compliance with the recommendations of your endo. Now, if you still need time to assemble information, the ability does exist to requests and extension. Are there any diabetic advocates in the area that could help. Debra Parrish is a lawyer out of Pittsburg and DC, She is on top of the process. Regarding my article from the American Journal of Managed Care, have you checked the references and pulled any of them to support your appeal. Do you, or your endo have access to your historical CGM Software data. I use Dexcom Studio and Clarity. If you do not, does your endo have multiple years of uploaded data at the office? Using personal data can go a long way to document the actions that you have been taking. Is there a history of hypoglycemic runs to the hospital? The goal here is to present the facts that you are doing everything you can and the CGM facilitates your ability of live a “normal” life. Last, go back in history to the original Diabetes Control and Complication Study. The study documented what happens when pump and multiple shot individuals attempt to reach A1cs of 7.0%. Do you want to go back to living in the 1980’s when the study did not have CGMs. You need the CGM. My thoughts and prayers are with you.
Dan
