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

Diabetes Technology Glucose Monitoring
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In case this ‘hear ye, hear ye’ wasn’t spotted on my blog, I’m pleased to say it again:

BREAKING CGMS NEWS!! Tenacity WINS!! DECISION OVERTURNED!!

My 13 month-long fight with my insurance company has taken a beautiful turn for the better. The third level of my appeal process was sent to an independent review organization (IRO) last month. The list of items sent included 39 documents, ranging from my bg charts, endo’s prescription and letter of medical necessity, academic articles and all the previous correspondences I’ve had with Regence.

I received a letter from the IRO yesterday saying, “It is the recommendation of this reviewer that the denial of coverage issued by Regence BlueCross BlueShield of Oregon for the Glucose Monitoring System is overturned.” :smiley: :smiley: :smiley: :smiley:

Here is another quote from the letter that I’d like to share:

“Even though CGMS in general is not considered the standard of care, in evaluating this specific case, CGMS would be considered the standard of care by the medical community. It would not be considered experimental because greater control of her glucose would result in improved health outcomes compared to standard therapy. The greatest potential for the CGMS with this enrollee is to monitor trend of variations in glucose rather than simply the highs and lows in blood sugar. CGMS can provide the trend of glucose excursion. This patient is prone to hypoglycemia unawareness. This feature in the Paradigm Real Time system could be valuable for her to identify hypoglycemia trend, thus allowing her to make an adjustment before a hypoglycemia event actually happens. In addition, there is an alert system in the machine that will alert the patient of hypoglycemia. The sensors features on the Paradigm Insulin pump will likely improve her glucose control, HbA1c and safety.”

Please feel free to contact me, share this news, reference this blog or whatever you need to help your own fight. May we ALL enjoy what should be the standard of care for our diabetes management, without having to go through the rather grueling process of appeals.

THANK YOU to TuDiabetes members Marci, Karne and Rick for their input, it proved invaluable. Thank you to ALL of the TuDiabetes members who encouraged me to continue this long and weary battle. Thanks to my family, especially my husband Michael who wasn’t so sure my tenacity would actually convince the insurance company, but he encouraged me to continue anyway.

Now, I just need to continue my diligence and patience - Regence should be contacting me soon. Maybe I’ll just go ahead and call them!! I’m so thrilled to have won!! What a day for a personal victory, the first day of the Olympics!

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That’s awesome! Your persistence has paid off, and your sharing will encourage others to do the same.

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CONGRATS!!! This is great news.

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This is great news. I have been following your appeal process. I work for a large hospital in Oregon that self funds our insurance. They use Regence BCBS of Oregon for the plan guidelines. I am preparing my second (I have been told my final) appeal for coverage for CGMS for my husband. I would appreciate any information you can give me for my appeal. It was suggested I find insurance companies that cover CGMS and provide their critera for coverage. I have been waiting for 3 months for them to respond with the documentation for which they based the first denial. We have been paying for the transmitter and sensors ourselves since January. My husband’s A1C has dropped 2 full points in 6 months and he no longer has hypoglycemic episodes. What a relief to be alarmed in the night with dropping BS. The CGMS data that he can download has helped him adjust his basal rates and the sensor readings have been accurate within a few points of his fingersticks. He now has so much more control over not only the low BS but high BS that he was not really aware of just using fingersticks. Thank you so much for all your hard work! Victoria

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Hi, been diabetic 56 years. Desperately need a CGM as my glucose numbers are all over the map. My last A1C was 5.9, however. Prob. cause’. the lows offset the highs. The frequent “lows” during sleeping hours are of particular concern. If not for my great wife, who handles emergencies like walking across the street, I would be in a coma, or worse. No question here. NONE! She, obviously, isn’t always at my side.
Just starting my appeal after being denied by Medicare Plus Blue. Have lots of data gathered.
I have learned, as with almost anything, their decision is all about money. When they are concerned enough that by you not having a CGM it will cost them far more, then they will show their sympathy.
Any advice or appeal stories would sure be appreciated.
Jim

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Someone said they keep making you appeal over and over because they hope sooner or later you’ll either give up, or die. This is probably right on for it is their jobs to save as much money as possible, not spend it. As with almost anything, the bottom line is money.
Jim

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I firmly believe that Ins. Co’s. have no good reason to approve CGMS. First, it should be known that they are in business to make money, not show compassion. The argument that in the long run it would be less expensive…, it just wouldn’t convince me at all.
What needs to be done is for all people reading this, contact a local newspaper, promise the lead scribe you have a story his/her readers will find very interesting, and one they haven’t heard of before. Newspaper writers are constantly under pressure to come up with something new. The papers have plenty of days when they need to fill space.Don’t be questioned on the phone, stick with your predetermined “bait” line (sound bite) and keep asking for a few minutes for an interview. You will get your interview if you can sound interesting for two minutes with your “bait.” Skip voice mail entirely! Get personally on phone with writer.
There is power in numbers my friends. Please, instead of bitching about Ins., get pro-active.
If enough articles continue to get out there across the country, important communication people will notice.
Eventually, a celebrity will get in contact with one of us knowing it shouldn’t be terribly difficult to get this job completed and help their career.
Talk show radio programs and political interest groups are not much more difficult than newspapers. They are all looking for hot buttons.
Having to appeal denials on CGMS will become a thing of the past in little more than one year, depending on how many active, determined, and knowledgeable Type 1’s are willing to invest three hours per week.
I come from this business. This will work.
Be happy to help in any way.
Jim Devlin