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

Diabetes Technology Glucose Monitoring
21

I have not been hospitalized for over 30 years and that should not be a reason for denying your insurance paying for a CGM because you have avoided that.

You want to avoid any possible complications for you and your baby and for your baby to develop normally and to start his/or her life free of any issues that could be caused by you not having the tightess control available to you being diabetic. Your insurance company needs to provide this tool to you so that you continue to avoid any future hospitalizations due to poor control causing even bigger medicals bills.

I will keep you in my thoughts and just a side note for you, just like the pump the CGM is not a cure and it still is just a tool to help you gain better control of a very unpredictable disease.

22

How did it go?

23

Hey, have you contacted Minimed??? One of the reps helped my doctor’s office write the request and put together a great packet. They approved me first time through. I am currently waiting to recieve it now. I also have BCBS, but it is of TN.
Let us know how it goes!

24

Yes I have been through it. I also have BCBS in PA/PPO but I was able to get a insulin pump with the CGMS. Now I don’t use the pump for insulin but I was approved for the pump . (regardless of the fact that it has the CGMS) which they have not yet approved. Backward logic. But I am now working on sensor reimbursement. I love the 522 Paridigm/MiniMed. Their reps were very very helpful even on Xmas day. Its not perfect but it sure helps.

Staci

25

Still going on my saga - I’ve met twice with the attorney. She is doing what she can to help, but it’s a bit beyond the scope of her usual role as university student lawyer. She’s trying to educate herself on this info. She wants to help me, but is quite tentative because it’s my last appeal with Regence BCBS and she won’t do anything that will cause her malpractice. I’ve got another week to finish off my tasks which are to:

• make copies of the FDA’s Final approval papers (I think I found the right one from the website - “Summary of safety and effectiveness data”, which ends with: " this system is safe and effective for its intended use when utilized in accordance with the product labeling.’"?)
• fax a request to BCBS for them to fax their forms to my attorney, including:

• policy #83 (the reason they deny me is embedded in here?- “Policy/criteria… # 2 Cont. monitoring of glucose in the interstitial fluid beyond three days is considered investigational.” This is always what they deny me on (using it beyond three days…how the heck else do you get trends???) BUT this is not what the FDA says! They say, when used in “accordance with product labeling.” SO>>>is that my argument there?
• authorization form so my attorney can speak with bcbs.
• and find out what the heck the Association Technology evaluation center criteria is all about.

Who knows. I’m tired and am fighting off a virus, so I’d just as soon have it all end happily, without any effort on my part - but that’s not how it works sometimes, is it?

Davis

26

Yep, minimed has been great. My rep was on the teleconference with me, even tho I was the only one who talked. It was good moral support. You should be thrilled - even tho we just get to poke ourselves even more now, ha ha! I’m jealous of you!:slight_smile:

27

Offer to replace it every 3 days per the FDA usage, if they so require. But DO point out that greatly increases their costs in comparison to “replacement Sensors as Needed to provide 24x7 coverage”, which is what your Endo’s Statement of Necessity should have specified.

(I think.)

You NEED TO POST the entire “policy #83”, or it’s URL, to get really useful advice from those who have won this battle. There’s more than one “BCBS”, and you need to show us the game being played by yours.

BTW, the last time I helped someone AFTER their “final appeal” denial letter was sent, the entire review committee overturned themselves and approved the requested pump-- in less than 4 hours. Faxed at 1 PM, phone call comfirming coverage just after 5 PM.

What they call themselves “Association Technology Evaluation Center”, or “National Gang of Denial Experts”, or “Church of Hubbard Scientific” (TAANS, BTW) doesn’t matter. There’s particular decision makers involved, and part of your next step is to threaten them professionally – as individuals.

28

Hi Davis,
Just wanted to let you know that I appreciate you for keeping us up to date with your appeals. Hopefully I won’t need to take your advice, but maybe I will. Today my doctor sent in my first appeals letter to my insurance company for both an insulin pump and a CGMS. I was denied the pump because I don’t have Type 1 diabetes. Which is correct, I have Cystic Fibrosis Related Diabetes, which is still insulin dependent, but since the case manager at the insurance company has never heard of CFRD I was denied. They also, like you, denied my CGMS because it is “experimental”. So thanks for your info and for everyone’s advice.
~Aspen
Salty and Sweet

29

Thanks for the feedback :slight_smile: I hope you won’t need my experiences either…

30

This is the link for Policy 83:
http://www.regence.com/trgmedpol/medicine/med83.html

This is for Oregon’s Regence BCBS.

31

Thanks, I read it over. They’ve tried a very SNEAKY trick in this document, you should call them out on it… by saying that it (letter draft follows)…

"Directly contradicts what the FDA-approved labeling says about using these devices on a continuous basis. They are ABSOLUTELY approved for continuous use by patients.

For example, the original Approval’s “Summary of Safety and Effectiveness Data”, available for them to READ and UNDERSTAND at http://www.fda.gov/ohrms/dockets/dockets/05m0454/05m-0454-aav0001-03-SSED-vol1.pdf, begins section II. INDICATIONS FOR USE, exactly as follows:

“The Guardian RT is indicated for continuous or periodic monitoring…”

And your medical need is for continuous monitoring. Individual Sensors are used for “up to 3 days”, but the usage of the RT CGMS system is indicated for continuous use.

Next, in your letter, if the you are hypo-unaware and DO experience Hypos without awareness (especially at night while sleeping and unable to routinely test bG each 1/2 hour): Warn them that HbA1C is merely an average, and that frequent, severe Hypos make the number “look better”.

Finally, ask them for “the names, medical qualifications, and license numbers (by State) of the persons who are responsible for this breathtakingly inept and incompetent policy.” Follow that with this sentence: “It appears that they are practicing outside the scope of their competence in ‘overturning’ my Physician’s letter of medical necessity, and Medical Board action (e.g., remedial training or disciplinary action) might be needed.”

Finally, say:

“Please provide a written response to defend your denial of my coverage, based on the absurdities and lies in this “policy”, postmarked on or before February 22, 2008. If unable to do so, please provide a written response, postmarked before by February 8, which explains exactly why you need more time to prepare this response.”

(You want to use a few really long-winded sentences with too many commas, like that, so that they hear you switching over to “legaleeze” LOUD AND CLEAR.

Good luck. If you’ve got documented “hypo at night” problems, You’ve already won. Unawareness by itself is a bit harder to argue, because they try to order you to “just test more”.

32

Ok, here’s a quick update.

My university student attorney compiled a nice packet of my case - I sent it to a more specialized attorney, who I spoke with this morning. I’m needing to send in the third (and last) appeal to pre-authorize the cgms. The 2nd lawyer says it would take between 10 and 20 hours to write a good enough letter! That’s a mere 6000 dollars! Guess what I told her? (“not feasible” = @#!!) I’m a graduate student for crying out loud!

I’ll just write the letter myself - unless there’s some attorney out there wanting to take my case on pro-bono???

Anyway, it’s been loads of energy and time for me, and I don’t regret pursuing it this far, but now I need to focus my attention on the final appeal and my new and improved diet. Especially considering all of the trouble people have in adjusting to the CGM, makes me wonder. Jeez, it sure can be frustrating, can’t it?

The two main arguments are: 1) Regence BCBS denies me flat out b/c “it’s considered investigational beyond three days” - counterpoint - no, FDA approved it according to product description (see previous thread from Rick).
2) they classify this whole thing on their medical policy. But the CGM is a durable medical equipment.

Anyway, that’s the basics.

33

After a few weeks of school work, I’ll take a moment to update anyone who is interested in my quest for pre-authorization approval. It basically is a limbo period, where OR Regence BCBS thinks I’ve given up. Actually, I’m just developing a strongly written letter of argument for my (final?) 3rd appeal. Rick offered to help me write this, but he seems wrapped up at the moment, so I’ll just do my best writing on my own.

I must get a cgms! There is no way I can keep the trends consistent on my own - even testing every hour 1/2 to 2 hours, exercising regularly and eating a low-carb diet. Yesterday, for instance, I was a guest lecturer for a course in which I used the usual professor’s slides. The nerves of covering her material caused me to spike up to 324 before the lecture. Not good, but absolutely foreseeable if I’d have had a high warning system in place. Man, I wish I could afford this technology!!

34

Have you asked them if they will cover the supplies for the cgms? When I called my insurance, they told me that they did not cover the cgms, but I went ahead and got it anyway. Dexcom filed it with my insurance and I was surprised when they started reimbursing me for the sensors. They didn’t share that part with me when I inquired. So if all else fails and they will help pay for supplies, then I say get the Dexcom (it’s cheaper for your out of pocket, the actual cgms) and they may pay your supplies at 80%.

35

Excellent idea…I need to think of possible alternatives like this. How much is the dexcom out of pocket? I think the mm is about a grand. I already have the mm paradigm, so that may be awkward to change… 80% coverage of the supplies would be conceivable though.

36

Well the website says $800, but I think when I bought back in Dec., that included the first set of 4 sensors too. I have a medical retirement VEBA fund that I used to reimburse me for the cost of that, so I actually didn’t have any out of pocket to start up. Do you have a flex-plan where you work that you could use?

37

Hi! I am currently fighting with Aetna PPO (2nd Level Appeal). Rick was supposedly helping me as well, I have not heard from him since March 19th. I really hope that he is OK. But I am finding this fight very difficult on my own. He was my “ace in the hole.”

What is the status on your fight now?

BTW–ECE is my passion!

Best luck to you

Marcy

38

So, after my 2nd appeal, with the assistance of my HR dept (told them I WOULD start civil legal action), and the assistance of all the help on this board… I just got BCBS to cover (least I have a letter saying they overturned their previous denial), supposed toget it next week-minimed says it is processing. Of course it did not hurt that I filed the appeal the day I came back from a week off from work ordered by the endo so I could get try and get my BG under control.

It really is just a matter of wearing them down so they KNOW you aer NOT going to go away. Idiots.Since the annual cost of the equipment is less than an ER visit in most places, you’d think that it would be a no-brainer for them…but we all already know logic escapes them most of the time.

39

Nice work!!! Congratulations.

40

This may help I am working on this now…

From JDRF’s website

STEPS FOR OBTAINING CASE BY CASE COVERAGE FOR CONTINUOUS GLUCOSE MONITORS (CGMs)

http://www.jdrf.org/index.cfm?fuseaction=home.viewPage&page_id=60525BBF-1279-CFD5-A739A8849799ECF9

http://www.jdrf.org/index.cfm?page_id=106687

i hope this helps…