Advice for insurance appeal, CGM

Type 1 and LADA
1

Hi,
I’ve been denied coverage of a CGM by my health insurance and am working on an appeal. Would appreciate any advice from experienced insurance-appealers out there!

My plan is based in Oregon. My endo is writing (another) “medical necessity letter”. I am not on a pump and prefer to stay on MDI for the time being. My A1C has fluctuated from high 5’s to 6.3 over the past 2 years or so. With MDI, I have had an average of 1.5 BG values per week in the high 60’s and about 2-3 times a week I will measure in the low 200’s. Of greatest concern to me is after heavy physical exertion I have dropped BG over 100 points in about 1 hour and I have to test like crazy to know how many carbs to keep me sane when dropping that fast.

The bottom line for their denial seems to be “there must be documentation of unexplained large fluctuations in daily BG values taken before meals, frequent unexplained episodes of low BG or hospitalization for uncontrolled BG.”

Anyway, the summary of my draft appeal letter is below, any advice would be appreciated. Does this have any chance with your basic insurance company or will it fall on deaf ears until I land in an ER someday? Thanks!

"1. My work…requires extreme variations of activity level. For example, some days I am in my office working on a computer all day, other days I am driving several hours to a remote hillside to assess a landslide (climbing up and down on steep terrain in adverse weather) and then driving several hours home, other days I am testifying in court, making public presentations, or participating in technical meetings with customers. I am required to clamber around on construction sites with strict safety requirements, where a hypoglycemic episode (if one occurred) would be very dangerous. There are many times where it would be impossible to stop and do a BG test with a finger poke.

It is well known that BG is difficult to control with widely fluctuating activity/exertion level such as I am required to provide for my job. I believe that accounts for most of the low and high BG readings I submitted to ___. It is also well known that cognitive function declines with high BG, potentially impairing my ability to work as a professional engineer. Thirdly, it would be hazardous and unsafe for me to risk low BG while on a remote landslide or driving to and fro.

(I then cite a few research papers I found that support CGM use for PWD Type 1’s)

In summary, ___’s arbitrary application of a “one size fits all” medical policy to my intensive multiple daily injection insulin treatment of Type 1 diabetes does not allow me to monitor my BG as closely as required for my job. My job requires better BG monitoring and tighter control than I am able to provide with finger pokes and 6 times daily testing. I need the CGM as a preventive device for my own safety on the job, and I need it for monitoring BG during/after physical exertion. Medical literature cited in this letter supports the use of a CGM for my condition. Please also note that the studies cited on this letter are 7 and 8 years old and CGM technology has improved a lot since then, increasing their effectiveness in BG monitoring and control.

If this appeal is denied I would like to request that ___ send me specific information (such as the actual medical policy as applied to my personal medical records) rather than a generalization in a denial letter. I will need this information to assess my options for further appeal or outside review."

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2

I can’t offer any advice but plenty of sympathy. UHC has decided to no longer cover my Dexcom. I am about to start my fourth appeal because I found out today that UHC directed my doctor’s appeal (appeal number 1) to the wrong department, leading the second and third appeal to follow suit. And naturally they never responded to the last two appeals, I had to follow up with phone calls after the response time had passed.

If you have any luck with your appeal, please post it here so maybe I and others can learn what to do. I’ll be sure to do the same.

Good luck.

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3

If possible (and it usually is), get your insurance company policy before you send your letter. That way, you can use their wording against them and also show how you meet their criteria. See your diabetes educator as they often have up-to-date knowledge of insurance requirements. Next, contact the local CGM representative and ask them for advice in what to say – they may know of people who have successfully obtained one. Explain why your request is “medically reasonable and necessary”, why their alternative has “more risk for serious complication” and why there is no comparable alternative treatment that is as efficacious. If possible, make a financial case for the CGM. Finally, ask that if denied, you get an expedited external appeal.

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4

I don’t have any advice either. But do hang in there. I think it’s ridiculous that they can deny coverage of such a NEEDED device especially when you have circumstances like yours with work OR like me, documented, repeated severe hypos when you are hypo-unaware!! I drove home in the dark one night having no clue that my sugar was under 50. (It had been 90+ less than an hour earlier)
It dropped to below 40 before I got so exhausted and mentioned wanting to sleep to my husband who immediately said, “Let’s check your sugar”… I have absolutely no idea when I drop low and the CGM could EASILY warn me before I get to the point where I can’t take care of myself. It’s maddening what the medical and insurance industries do to us. I feel very safe in saying that the majority of the stress I feel on a daily basis is from worrying about what insurance/medical facility will or will not do that affects me in a major way, ya know? ARGH! ahem Sorry to go off on a rant. I’m dealing w/some of their stupidity right now. Hope all goes well for you in this. You definitely need the CGM too!

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5

Has your doctor requested to do a peer to peer review with the Medical Director of your plan? That is really the first step. A lot of times if your doctor will call your plan and do the peer to peer review, the two physicians can discuss the situation and you would be surprised how many times a situation is more clearly explained when the two doctors discuss it than what it appears on paper. I work in insurance, and doctors documentation many times is AWFUL in fully describing the situation, however when denied and it goes to peer to peer review, it is clearly explained to the Medical Director and then approved. While I’m not saying your doctor’s documentation is awful, working for a health insurance plan, we can ONLY go on what doctors submit, and you would be surprised how often what we get just is awful documentation. If it’s NOT clearly documented, how can it be approved? I know insurance can be a sore spot for people, but I did want to give another perceptive of the situation, and why things that to us in our situation make sense and how can they deny this…often get denied, Many times its not your insurance company just being a$$holes, its what we receive to base our decisions on from doctors. I would ask your doctor to do that versus submitting additional info for a “reconsideration”. If for whatever reason the denial is upheld, then you have the option to appeal.

I do think though your appeals letter is very well written, and for the company I work for, I think would have a good chance of being approved on appeals. I also agree request a copy of the medical policy they use to base their decisions on. That way you can clearly see what their policy is and address it in your appeal letter.

6

I agree, a peer-to-peer review between your prescriber and the CMO of your health insurance company may be the way to go. Whenever I prescribe a medication for a patient that an insurance company denies (and this practice of denial has increased exponentially over the past couple of years to the point where many generic medications are now denied!) I first play the “Prior Authorization Game” (at which I have become quite adept if I do say so myself, and currently win about 85% of the time) or I go straight to the top and ask to speak with the CMO if the prior auth. is denied.

I’ll tell you about one such encounter with a health insurance company CMO which I found particularly enlightening. Let me first say that my goal when it becomes necessary to prescribe medication for a patient is to start with the least expensive generic that I believe may be effective, prescribe it at a low dose to avoid potential side effects, and then increase the dosage gradually until one of three things happen: the patient experiences intolerable side effects that do not go away in short order; the medication is not effective at what should be a therapeutic dose after an adequate trial; or (hopefully) the medication is effective without causing untoward side effects. If the third desired outcome does not occur, I move to another class of medication and choose the most affordable generic in that class. Rinse and repeat. As sometimes occurs, an effective medication is not found after the first go-round through all the indicated classes and I need to try a generic medication off-label (if one exists that has a “trial record” of success in treating the patient’s particular symptom/symptoms.) If a generic prescribed off-label isn’t effective, then I must go for a brand-name medication for which a generic is not yet available. This inevitably (over 90% of the time) triggers a denial and the “Prior Authorization Game” begins. I think what irks me the most is that the “team” of individuals who decide to approve or disapprove medications I prescribe are not (and may not ever have been) clinicians treating patients “in the trenches.” That, and how long it frequently takes to get to this point, which means that a patient is left suffering longer than they should, and their health insurer ends up having to spend considerably more than had they just trusted my medical judgement and covered what would have been my first-line choice of medication from the get-go. But I digress. Back to the original story: After having run the gauntlet of approved generics in my attempts to treat this particular patient, I prescribed a newer brand-name medication indicated to treat my patient’s symptoms for which I had free samples. Fortunately, that medication was very effective and the patient had no complaints of side effects whatsoever. So I went ahead and wrote a prescription for the patient to fill, knowing full well to expect a denial for insurance coverage and a fax from the patient’s pharmacy informing me that a prior auth. was required. I had the completed prior auth. ready to go before I even received the fax from the pharmacy, and submitted it to the patient’s health insurer. (At this point, many of you are probably asking why I didn’t submit the prior auth. prior to my patient’s attempt to fill the prescription. I have learned many times over the hard way that 9 times out of 10 when I have actually attempted to do this in a manner that makes sense to anyone with an IQ in the higher double digits, one of the following scenarios ensues: 1. The health insurer sends me a fax stating that they cannot approve or disapprove a medication that hasn’t actually been prescribed yet. 2. I must have made an error in submitting the prior auth. because said patient is not actually taking the medication in question and they need chart notes documenting the fact that the medication is effective even though I already submitted said notes documenting efficacy during a trial with samples along with the prior auth. request or, my favorite response to date, 3. I receive a fax stating “This medication does not require a prior auth.” But when the patient then attempts to have the prescription filled, coverage is denied with the reason being that a prior auth. is required.) After coverage for this medication was denied and my prior auth. (including documentation clearly proving beyond a reasonable doubt that this medication was effective and all other covered formulary alternatives were ineffective) was then denied, I called the health insurer and, after being transferred no less than 6 times and disconnected once, I called again requesting to speak to the CMO. She, not surprisingly, was not available to take my call and I left a voice message requesting a call back. A ten-day game of intense telephone-tag then occurred before I was able to speak with the CMO. I respectfully and concisely presented my case for why the cost of this medication should be covered by the patient’s insurer, and lo and freakin’ behold, she approved it! After thanking her, I asked why this exceptionally time-consuming prior auth. “dance” needs to occur in order for me to do essentially what I became a physician to do in the first place: make my patients feel better. Her response shocked and surprised me. She said (and I paraphrase) “We don’t approve the vast majority of non-generic medications because most physicians use the closest sample medication they can reach because they are too lazy to write a prescription.” WTF?!?!? I lost my patience at this point in the conversation and said something along the lines of “Did you actually listen to what you just said? Why would any physician of sound mind start using a brand-name sample for which no generic exists to treat a patient before they had already exhausted every other insurance-covered possibility under the sun, when they know full well that the less-than-one-minute ‘hardship’ of putting pen to paper and writing a prescription for the effective sample medication will result in the time-suck to end all time-sucks, the “Prior Authorization” game?” Her answer? “Well, I guess you’re different than most physicians.” I said “Thanks, but no thanks for the compliment, and I think you are sadly mistaken about ‘most’ physicians.” Sheesh…

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7

Truth be told, I’ve had SEVERAL doctors in my history of doctors (and I’ve seen a lot of doctors due to moving, switching insurance, etc.) who were very quick to pull from their sample closet before choosing a generic. That said I’ve generally had pretty good insurance where it was a case of generics would cost me less, and I didn’t need pre-authorization for a non-generic, I just had to pay 3x as much for a non-generic.

I don’t know that it’s a case of being “too lazy to write a prescription”, though, so much as the assumption that these newer, name-branded drugs will likely be better than old stand-bys. After all, if the old stand-bys were good enough, why would we need the newer fancy name brands?

I had one Endo in particular who was very hip on Rxing the latest and greatest new thing on the market. At one point he put me on Onglyza. My H-CRP test went way up, indicating increased inflammation in my body, and my cholesterol levels went up despite marked improvements in my diet. My HbA1C didn’t actually improve but about .2%, but he thought that was such a great result that he wanted to put me on cholesterol medication to correct the problems caused by the Onglyza.

8

Thanks, I understand the peer to peer discussion betw my endo and the insurance company might work out as the most effective next step. I am going to try this as a next step. I gave my endo a summary list of the concerns I was going to put in the appeal letter so she has all the background on my varying activity/exertion level concerns. We’ll see how it goes!

9

John58, your efforts will make your physician’s attempt to appeal your unfair denial much easier, and I hope they will be appreciated! Good luck and let us know what happens.

10

This is just one of the most irritating aspects of dealing with the agents on the far end of the toll-free “assistance” call. Not a single bean counter @ the powerful “control the costs” companies seems to comprehend that the amount of time spent responding to your calls represents significant costs that could be controlled by listening to doctors and patients. Sheesh!

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11

Well, the peer to peer discussion did not gain insurer coverage of the CGM, and I submitted paperwork for an appeal about 10 days ago. Hope to hear back soon but (as I’ve posted elsewhere on TD) I’m pessimistic and most likely self funding a CGM pronto.

When working on this appeal I found his 2013 paper that concerns me about the ADA and whether they are effectively advocating for individualized self management options (such as a CGM) for PWD or just funding broad brush clinical studies: http://care.diabetesjournals.org/content/36/Supplement_1/S4

12

Well I got the letter today…appeal denied. One part of the letter that illustrates what’s rotten in Copenhagen was:
"…you have fluctuations in pre-prandial glucose values but you lead an active lifestyle that would explain them" (the medical policy says CGM is covered if a person has “unexplained large fluctuations in daily pre-prandial glucose values”). In the meantime I charged a Dexcom G5 setup to my Visa card and have started using it, so far so good despite getting screwed by my insurance company.

Anybody out there know of an advocacy group looking into these medical policies used by health insurers to deny CGM’s and limit test strips? I am considering going outside the appeal process somehow but don’t have any red hot ideas how to go about it.

13

That sounds awful. I’m sorry you’ve had such a negative experience- pardon the understatement.
Some insurance companies are more rejection happy than others. Does your work give you more than one option for health plans?

14

So sorry to hear this. You might find something useful at this site:

http://cgm-antidenial.ning.com/

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15

Believe it or not, I am really happy with my insurance plan for everything except this CGM denial. I pay a lot of money for the insurance, and with the insulin, test strips etc cost plus my wife had a hip joint replacement this year, I have no complaints at all about the copays, deductibles etc. The insurance company paid out a lot of dough on me and my wife the past few years, many times more than I spent on the insurance. So no complaints there.

From what I’ve seen so far, this CGM denial problem seems to be rampant with a lot of insurers but not all. I am going to try to find an advocacy group of some sort who can help me figure out the details of this issue. I’m quite baffled why some private insurers cover it and others can cite “clinical studies” and deny it. I thought they all had to follow the same basic rule book about what’s “medically necessary”.

So far I am not happy with some of the info the ADA has put out that state insurance regulators are using to support denial of CGM coverage until we have multiple hypo’s or land in hospital with DKA, and after that it’s covered. However I tend to be pretty cynical so I want to find some groups with a more objective view and see what they know about how insurers are allowed to define a CGM medically necessary or not.

Stay tuned, if I find anything out I’ll post it.

16

I don’t know if you went to the link I posted for you earlier in the thread, but it’s a group specifically formed for assisting with CGM denials.

17

I have had 5 appeals denied for my Dexcom so far. I am waiting for the hard copy of my last denial so I know my next step. Just went and joined the CGM anti-denial web site. Just still don’t understand how they can stop coverage after they covered me for 2and a half years and the only reason is that Medicare doesn’t offer coverage. My health didn’t change.

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Shadow2, Thanks that is just the kind of group I was looking for!

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19

I know one thing United Healthcare is that you must show at least 4 low blood sugar results within a 30 days.

20

I’ve heard tell that some folks have accidentally taken a little too much insulin (perhaps they made an error in their carb calculations or weren’t wearing their reading glasses and couldn’t clearly see what their pump’s bolus wizard suggested, etc.) Fortunately, these folks are all ex-Boy Scouts and ex-Girl Scouts who take the “Always Be Prepared” motto seriously, and keep glucose tabs or juice or Smarties on their person 24/7, so when their BG has for unclear reasons gone as low as the mid-70’s as documented on their meter several times per week for several weeks in a row, they were able to immediately treat their lows and relatively quickly returned to nice, safe BG levels. Because these ex-Scouts always have fast carbs within reach, thankfully none of them ended up meeting any easy-on-the-eyes paramedics, nor did any of them need to break open their bright orange boxes containing their rescue glucagon. Unfortunately, some of these folks accidentally over-treated their lows when their trusty meters indicated that they hadn’t returned to an over-100 BG level after 15 minutes. They know this because they tested and their high BG readings are documented on their meters. These poor folks with BG’s that roller coaster all over hell and back were able to provide hard evidence of their volatile BG’s via their BG meter’s records to their benevolent health insurers whose “raison d’etre” is to provide the best care possible to their insureds without care for their profit-margin or rage-filled shareholders. And, as it inevitably comes to pass in this perfect world of ours, these folks’ friendly and helpful health insurers (whose insureds never have to navigate up to 10 levels of recorded options to reach a live person and who never once were placed on hold for over 30 minutes only to be accidentally disconnected) approved coverage of their game-changing and life-sustaining CGM devices faster than you can say “Bob’s your uncle.” And not only because their health insurers are wise and realize that ambulance trips to the ER for treatment of lows or hospitalizations for DKA or ongoing treatment of diabetes-related complications would cost them more than covering part (because the remainder is covered by their insured’s astronomical deductibles and co-payments) of the ongoing costs of utilizing a CGM, but because they truly care. :wink:

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