Aetna PPO—Approved my CGM—first appeal @ 90% coverage
–I sent 2 letters from my Endo—I typed both endo letters(basically copied from the sample letters that Dexcom provided), emailed them to my dr and let her fill in the diagnosis code(which I had researched and suggested her to use 250.83— which is something like “Diabetes mellitus with other specified manifestations Type I uncontrolled” ) — which if they needed elaboration on, she was prepared to write an additional letter about hypoglycemia unawareness related to my specific case.
–sent a personal letter describing my specific need
–sent an excel spreadsheet - 4 months worth of color coded with highs and lows marked in different colors. (see attached—if you want to feel better about your control, look at this)
—sent average meter tests per day relating to A1C results.
A1C 7.3% testing 4 times per day
A1C 6.6% testing 6-10 times per day
A1C 6.0% and 6.1%, using CGM testing 3-4 times per day
—sent documentation of Pre-CGM A1C results and Post-CGM A1C results
First Appeal approval is unheard of in past experience…maybe Aetna is finally coming around.
Hope this is useful information to some of you.
8646-predexbs.xls (78 KB)
8647-lettertoaetna.doc (29.5 KB)
Thanks, Mollie-we are considering getting a CGMS for our Son, Aaron, in the next year or so. Hopefully, by then it will be covered with no problems, thanks to trailblazers like you.
What GREAT news! And thanks for the spreadsheets which may help others to persuade their insurers too.
Best of all, it’s wonderful that the CGMS helped you make such a huge improvement in control.
I am about to send my second appeal to Aetna for the CGM for my 16 year old daughter. I hope that they approve this one, if not I am not sure where to go from here. Thanks for your info, I am going to attach her readings on a spreadsheet like you did.
Lordie, I went through my appeal process with my previous insurance and won, and this your our insurance changed to Aetna and I just ordered more sensors last night, hope Aetna pays, ahhhh!!!
Medtronic rep did state to me back in December when I won my appeal that she had a special deal with Aetna and there would be no problem, hope she was right.
Hey I still have the email, this is what she said:
Also, for ongoing sensors orders, Donna stated that as of January 2008, claims will be going through a different processing office. Just FYI, when you do need to reorder sensors, we will probably have to contact the new claims office, which is through Aetna. We do have single case negotiated contracts for sensors through Aetna, so when it comes to new sensor orders, the process won’t be the 6 month headache you’ve had to go through.
Crap I did not contact the claims office, now what will happen, guess I better on Monday, or perhaps not, just wait it out and see if they pay, grrrr.
Thanks, Mollie. I am covered by Aetna as well.
Not sure exactly what the last sentences mean exactly—also my second claim was only covered at 70%—but Aetna’s policy was updated recently to read as follows…
Continuous Glucose Monitoring Devices:
Aetna considers continuous glucose monitoring devices (e.g., MiniMed Continuous Glucose Monitoring System, Guardian Real-Time Continuous Glucose Monitoring System, and the DexCom STS), which are used to continuously monitor diabetic persons’ blood glucose levels over a three-day (72-hour) period, medically necessary for persons with type 1 diabetes who have either of the following problems in controlling blood glucose level, unresponsive to conventional insulin dose adjustment:
repeated hypo- and hyperglycemia at the same time each day; or
No more than two CGMS monitoring periods are considered medically necessary within a 12-month period. Aetna considers the long-term use of continuous glucose monitoring devices for home self-monitoring of blood glucose experimental and investigational.
Crap this is not good for me. Just when I won my appeal through my old insurance they changed to Aetna, and now I am using the CGM a lot.
I am sad.
it could be just the standard that they are starting to approve without appeal for the 2 sessions…maybe if you appeal and get your letters from Dr and show hypo unaware, dawn phenom, fluctuating glucose, they will continue to pay…i am sending my 3rd claim in later this week…will keep you posted.
This is the response from my medtronic rep.
Still here; I was promoted to a new department, but can still assist.
I would definitely suggest contacting Aetna to see where claims are sent. When you start your reorder, let me know and I will contact the
representative on the Supply Order team to explain the authorization.
Man I already ordered just thinking I could since I was with same company and my medical ins. previous appeal would still continue. I am stupid sometimes when it comes to all of this red tape, this is almost harder than having the darn disease itself (not really of course), and the anxiety I have now, ahhh!!! and I found out that they are no longer making freestyle flashes and my meter is old and I have a mega supply of strips, ahhhh!!!
So are all of your sensors being covered?
Mark not sure who you are questioning but my old insurance was covering 100% on sensors, not sure Aetna will do the same. I think I spend money every day on diabetes. This disease is far too pricey and I am also paying with my life as I sit here most of the day above 180 and now over 240 and cannot figure out why except the little bit I did eat was always on a bit of a high. Seems once you go high and eat you cannot get it back down.
Ready to pull both my sensor and my pump sites out in a minute, I am soooo upset.
I was asking Mollie about what insurance is covering for her.
Sorry you are having a hard time controlling your BG level, don’t give up though!!!
BTW, I agree 100% that this disease is pricey.
My insurance company’s policy is more of the same - CGM is only covered for 72 hrs 2xs/yr. WIth your extenuating circumstances (the unawareness), it’s great that Aetna saw the value in approving the CGM outside of their standard policy guidelines. My doc is about to hook me up for yet another 72 hr stint. Since I’m not in dire need right now, I’m going to wait it out a few more months to see about getting the pump w/CGM, like the MiniMed Paradigm. I just had an appt with my endo today, and he said there is more technological progress to come. (Just to point out, I’m not on any pump yet – I’m using Lantus & Humalog, and testing several times a day.)
Anyway, I also want to say, your supporting documentation is very comprehensive and compelling, and I’m sure that was the reason you were approved. I actually work for a health insurer (not in the appeals department however), and it really does take them to be convinced beyond any reasonable argument. So good job!!! That makes me want to contact my auth dept just to test the water. Even if I don’t plan on getting a CGM of my own for another few months, starting early always helps!
Just got my $0.40 (forty cents) check for my $350.00 sensors today from Aetna, WTF!!!