AUG. 08 UPDATE -VICTORY! Advice on insurance appeal please (teleconferencing in 3 days!)

Diabetes Technology Glucose Monitoring
1

Hi everyone!

I have been applying for a minimed cgms for many months now. On Jan. 2nd I’ll be having a 15 minute teleconferencing session to plead my case with my Regence Blue Cross Blue Shield of Oregon Appeals Panel. The panel is a physician Medical Director, a Registered Nurse and an Administrative Rep.

Regence has denied my request for a pre-authorization on the grounds of it being ‘investigational’.

Aside from the usual “here are the top 3” reasons why approach (which in my case are: plans for pregnancy, occasional hypo-unawareness and a constantly changing level of stress and activity which tends to make me be out of control…) what other persuasive methods work with these insurance giants??

SO, what has worked for you? Has anyone gone through this process and succeeded? Any recommendations big or small would be helpful. Please hurry with lots of advice!

Thank you all tremendously.

Cheers,
Davis

2

I have gone through the process and won recently but I did not have to do a phone confernece, I just faxed in a very lengthy appeal letter and a lot of documentation that I have posted on this website.

http://tudiabetes.com/forum/topic/show?id=583967%3ATopic%3A8717

Be sure to make it clear that it is necessary durable medical equipment and that insurance companies cannot deny that.

My letter is at work and I won’t be there until Thursday otherwise I would email it to you. :frowning:

Oooo and check out all the information on this forum there are 4 pages of help here. :slight_smile:

3

Minimed should have a rep do this with you along with your doc, but I can tell you that with my doc even appealing to BCBS of Georgia they turned me down flat stating that I am “in too good of control” although my A1C is still above 7.0 and my glucose levels are still all over the map.

Good luck with it all. Please let us know how things turn out.

4

Thanks Karen…

I’ve already taken as much ‘advantage’ of all the great info here. The point about emphasizing the durable medical necessary equipment is a great reminder. Thanks! Wish me luck.

5

Penny,

Good idea, I’m asking my Minimed rep to be on the appeal panel with me, he’s always been very responsive and more than helpful, so we’ll see soon enough! Gosh, I can’t believe they used the excuse that you are in ‘too good of control’ that’s crazy, really. Are you still pursuing getting one?

6

Are you in Oregon? I am here in Washington, have Regence Blue Shield, and have never had an issue getting a pump. I am on my third pump now, and they have not given me the run around any time. I did have my endocronologist write a letter, but that was all. Best of luck!
-Toni

7

Davis…I could not just get a CGMS system but could get an insulin pump…go figure the cart before the horse. So my Dr sent in a letter of necessity and I now have the pump; Paradigm 522 that serves as my CGMS. That I did not pay for…the MM rep suggested this and it worked. But I still have to pay for the sensors as far as I know. 2008 will be the year for the sensor reimbursement decision. I am not using the 522 as an insulin pump as of yet. So far it has worked fine. There is a charge for the transmitter and start up kit…like $900+ that minimed will finance at $52 a month with no interest…just an FYI.
Staci

8

Well…

I had my teleconference last week, and Saturday, I received another denial. I cried and cried, actually. The wording of the letter made it sound like they didn’t even listen to my appeal. I prepared it for an entire day, after spending weeks and weeks gathering materials of support. This was a very persuasive argument I presented. The folks on the panel must not get paid if they allow this…or else maybe they are just heartless. Apparently I just need to be admitted to a hospital before they’ll approve it for me! Stinking BCBS of Oregon. I’m not impressed and I plan to send in the paperwork for the next level of review - independent, outside of BCBS. The ludicrous thing is that I KNOW in a few years, there will be wide-spread insurance coverage of the cgms for home usage.

Thanks for everyone’s support and I’ll let you know how it goes, but for now, I’ll just keep testing 8 times a day and wondering what is happening to my sugars when I’m not testing.

9

J…you did have a letter of necessity from your doctor right?

Staci

10

I am so sorry about you not getting your cgms. Keep appealing it until they say yes. Keep giving them reasons why they need to approve.

11

Oh yes, my endo wrote a great letter, full of valid reasons why they need to grant me this one tiny wish:)

12

Darn it, Davis, you should have asked this within the “CGMS sub-group” area. (Or, I should come “up” and view the main page from time to time. Sorry!)

Since they’ve already denied you twice now, I think that you need to have A LAWYER send a short letter, on their letterhead. The fundamental response to their “investigational” assessment is to have the letter ask exactly who, why, and how BCBS claims to have “experts” more qualified than the FDA review panel to declare this device to be merely “investigational” – When FDA has in fact approved it for general use, over two years ago! The letter should state, as fact (don’t even allow an argument to take place) that “Investigational” means "still in Preliminary Market Approval (“PMA”) status with the FDA. (And MM R/T, the exact same Sensor device as Guardian, was promoted from PMA to general approval way back in 2005.) Conclude your letter by requiring that they stop this nonsense, stop pretending to “know more than the FDA”, and cover the device and supplies, long ago approved for your specific medical need, without further delay. Stop pleading, start THREATENING!!! (law-office letterhead does that, automatically :)) ).

Now in fact, I have posted a good deal of material in replies on exactly this subject within that area. Look at this one,
http://www.tudiabetes.com/group/cgmusers/forum/topic/show?id=583967…

but ignore the stuff about that case’s focus on A1C. (Unless, of course, your insurance IS trying to use “doesn’t improve A1c” as the basis of their nonsensical “still investigational” claim).

It saves time and money for you to draft the letter for your lawyer, that way there’s just a short talk and they don’t have to compose the whole letter from scratch. In fact, cut/paste this post for them. And you should join the CGMS sub-group, ask CGMS-specific questions in there. Finally, be sure that you’re using the correct (and brand new, effective 1/1/08) HCPS codes in your claims, not the old “1399” or similar “anonymous” ones.

13

Yes, yes, yes keep appealing. Don’t give up. That is exactly what they want you to do.

14

BTW, my Nevada “Anthem” BCBS didn’t even deny me once-- they accepted my first claim with no arguements, no need to Appeal. Just get your ducks in a row and then FIGHT, don’t BEG.

15

I contacted ADA when I was denied the first time. Here was their response to me:

Thank you for contacting your American Diabetes Association. We have received your e-mail regarding a claim.

Most laws regulating health insurance are developed and implemented by the 50 state governments. As a result, the health insurance options that exist in one state do not necessarily exist in another. You may contact your State’s Division of insurance. They might be able to assist you. The contact information can be obtained using the link provided below. We are also attaching information on what to do when your insurance company denies a claim.

http://www.diabetes.org/advocacy-and-legalresources/insurance/overv…

Here is the link on what to do if your insurance company denies your claim that they sent to me.

http://mail.google.com/mail/?ui=1&attid=0.1&disp=vah&view=att&th=115ecba6b6cc659f

16

Useless form letter. (And BTW, ADA’s chief scientist seems to think that even regular bG testing isn’t “proven” enough to justify insurance coverage. ADA is not your friend, or mine.)

“The State Division of Insurance” will almost certainly NOT investigate one individual claim which hasn’t even been brought to the proper authority yet. You have a contract dispute, in which they’re supposed to cover “medically necessary treatments” but claim that this particular treatment falls into an exception. (Which is written into your contract; if it is only in experimental/investigational status, then they CAN refuse to cover it.)

Where do USA citizens and Companies settle contract disputes?? Civil Court. THREATEN them with civil court action, and they’ll probably cave immediately-- because they know that they’ll lose this question:

"Is the device APPROVED for patients with hypo-glycemic unawareness and a history of dangerous bG excursions, or is it still in “Preliminary Market Approval”?

There is absolutely, positively only ONE answer to that question. You win, and they lose. They know this. So, they will agree to cover for you, because losing a civil court case sets a referenceable precedent for CGMS devices (very bad). It also creates a lost case against THIS particular MD in Civil Court, and that’s even worse-- every time he renews his license in the future, he’ll have to list the case, show the details, and (in general) fill out tons of paperwork to show that he IS competent.

If it doesn’t sound like I know what I’m talking about, you certainly can go ahead with ADA and State Regulators and more appeals and whatever. But they’re not the appropriate venue, and they probably won’t work. You won’t have to go to Court-- just the THREAT, with such severe consequences and the near certainty of losing, is enough.

Does your medical record include specific instances of these Hypos with Unawareness, and dangerously varying bG’s ??? Because, if they’re not in your records, they aren’t “reliable”. Even direct testimony by your work-mates and family is open to attack, so be sure that your records are complete.

17

Rick,

Tell us how you really feel. :wink:

I feel my insurance company denied more than just the CGM without truly investigating my case or anyone’s case seeking approval for durable medical equipment that crossed their path. I truly felt like they denied it and gave me no claim number to even appeal as just a normal process for them. The branch manager, where I work, stopped at my desk the other day and we were talking about our new insurance company coming in this year right after I won my appeal and he stated how our old insurance denied the helmet his new baby needed to correct her flat head from sleeping on her back. He stated he felt like it was just straight denials on anything out of the norm that you were applying for and like you stated Rick he was going to seek out obtaining a letter from his lawyer. So like you stated, that was going to be my next step or use the website of how I was going to report my denial to the State’s Division of Insurance. That is why I posted it. I think insurance companies push things through when you even know to report to the State’s Division of insurance or are going to seek help from a lawyer. I think just the wording in your appeal letter could move things forward.

18

I truly appreciate all of your replies. I like hearing the real deal, it’s refreshingly reassuring. I plan to plunge into more hard-hitting language with this last appeal - I’ve got an attorney I can call on. Help me stay motivated though, as I’m a full time graduate student with a thesis to write, a paper presentation to have ready by next month (etc…) and not enough time to do it all!!

I knew to have a legal case in the wings, as my statistics prof from last term (who used to work for the FDA), gave me the same advice. Regardless, when BCBS finally got back in touch with me, they gave me very short notice that we’d be teleconferencing - hence my lack of preparation time. Now I’ll go ahead and write up a detailed tough appeal…again, thank you for the great ideas!

19

Karen, that was funny-- yes, I’m talking very “short” and hard-nosed because I’ve given similar advice to others many times, even though it’s brand new to Davis.

Davis, I think that you should REFUSE a teleconference, and insist that all further communication be done IN WRITING. They’re using this “video-with-too-short-notice” as a tool; they want you to say something spontaneous and erronious on their video tape (it’s a setup). They are EXPERIENCED PROFESSIONALS at trying to trick you in to a mistake, that’s their job. (They’ll only do “care” if they have to, they’d prefer to make PROFIT.)

At this point, all which your attorney needs to do is listen to your SHORT story and confirm the facts in your letter draft (look at the FDA’s definitions of “PMA” versus “Approval”, look at the Minimed Approval Announcement of December 2005, and review their denial letter. It shouldn’t cost a lot, I think-- but you need the insistence that future correspondence be WRITTEN, and the clear statement that the device is approved and NOT investigation to go out on his letterhead.

You’re making a great move. Now, try to focus on those details in your history which CAN’T be resolved by simply doing more fingerstick tests. (Hypo unawareness is kind of the first step, not the “clincher”. If you’ve had nighttime ambulance calls or Glucagons, as I have, that’s A+++ and constitutes a slam-dunk. Pregnancy plans are a good item, but somewhat strong a case than dangerous bG while sleeping). Your stats prof sounds right on the button-- the ADA doesn’t, not at all.

20

Karen, Rick and others,

Just a quick update. I’m meeting tomorrow with the university’s “student attorney” who handles consumer issues. I’m a grad student, so my student fees pays for this service. I’m counting on her doing the case with gusto:D

The plan is to enlighten her to my case, writing up a letter threatening them with civil court and getting a CGMS. I did tell them during the teleconference two weeks ago that I’ll do whatever I need to do to get one… This is what I mean. Off I go!

I’ll keep you posted.

BTW, I haven’t had any emergency nighttime situations, thank goodness and sheer luck, I think. I haven’t had any emergencies/hospitalizations since 96. My main reason for needing the CGM, above and beyond all others, is the plan for pregnancy.

Thanks for your support!