I'm hoping to get a CGM in the next few months, possibly with an Animas Vibe, and I'm wondering if there are certain insurance companies who are more likely to approve them. It would be great if people could give their experiences with various insurance companies and if they have specific criteria for approving a CGM.
I buy insurance on the ACA (Obamacare) exchange and am willing to switch companies if it will improve my odds of getting a CGM. I doubt anyone has experience with my current insurance company, Arise (WPS), which is local, but I have other national options, such as Anthem BCBS and UnitedHealthcare.
One thing you could do is google for information regarding CGM coverage for a specific insurance company before you sign up for it. Here's an example of criteria for one company:
I use a Minimed 723 pump and a Dexcom CGM. I have United Healthcare and have never had any problems with them paying for anything. They haven't asked me for any records or such things.
Glad to hear it. Here is what I found for UHC's criteria. Did you fit into either of the two guidelines? I really don't.
"Long-term continuous glucose monitoring (greater than 72 hours), alone or in combination with an external insulin pump, is proven and medically necessary as a supplement to self-monitoring of blood glucose (SMBG) for patients with type 1 diabetes who meet EITHER of the following criteria AND have demonstrated adherence to a physician ordered diabetic treatment plan:
• Have been unable to achieve optimum glycemic control as defined by the most current version of the American Diabetes Association (ADA) Standards of Medical Care in Diabetes; or
• Have experienced hypoglycemia unawareness and/or frequent episodes of hypoglycemia"
Cigna, has/had one of the 'worst' reputations when it comes to pumps & CGM, from what I have heard.
They are one of only a few that typically require one or more of the following: Certain C-Peptide levels, recurrent severe Hypos, DKA, positive antibody tests, renal problems, age limits, HbA1c >7.0, etc.
They also require folks to complete an education program, be on MDI (3x or more/day) for 6 months, submit documentation showing 4/day BG tests for the past 60 days, self-management ability, etc. etc, etc.
Their coverage position criteria is rather 'comprehensive', a.k.a. confusing.
That is what I was faced with when researching prior to getting my pump. So I spent a week preparing for an appeal even before we submitted the order.
Medtronic received the 'Statement of Medical necessity' on a Wednesday. On Thursday, I had a conference call with them and Cigna to verify coverage (where I was sure to hear Cigna's list of 'demands'.)
Except coverage was approved no questions asked - and I mean no questions, at all. Gigna simply told us that I was covered at 100% (had already met my deductible and out of pocket max.)
Got a call on Friday with the tracking number and my stuff arrived Tuesday morning.
It is important to ask the companies prior to signing up. I have had no issue with Anthem BC/BS but that then again I am in an employer sponsored self insured plan with a specific provision based on need. Other Anthem plans do not have that provision and the threshold is higher in those plans. It is way more than just the insurer. It runs to the type of plan, the degree of employer support if any and the minimum requirements of your state. I am in Indiana. I urge you to call plans and ask their specific requirements, usually for durable medical monitoring devices which are determined to be of medical necessity. It is doubtful that any agent who picks up the telephone will know what a CGM is.So while you can ask directly you may not get the answer you need.
By and large in my experience, Employer plans are much more flexible. Private purchase (including the insurance exchange) plans are much less flexibility and will cover much less. Almost no medicare supplemental or wrap around insurance will cover any CGM purchase. Typically the medicare wrap around plans only cover items covered by medicare. Since CGM's are not currently medicare eligible the wrap plans will not cover any part of the expense.
If you feel this is unfair, I certainly do, ask your sates senator to co sponsor S.2689 and your representative to co sponsor H.R. 5644. This is extremely important.
I don't meet either of those conditions. My A1C has been around 6.5 for several years, and I am aware of lows, which I rarely have. There must be different criteria for different plans.
And please bear in mind that all of this discussion applies only to those with a Type 1 diagnosis. If you have type 2 all bets are off and even the bills that Rick refers to won't help. My insurance (despite quite liberal requirements for T1) considers CGMS as experimental and investigation for T2.
I think most insurance company's today will approve a CGM if it's a Medical necessity. UHC approved my CGM in 2007 when everyone was saying they would never approve a CGM. I think my doctor did a good job explaining my need for a CGM. Having a doctor that advocates the use of a CGM is probably the key component in the approval process.....most states have laws that required a insurance Co. to cover Medical necessity, these laws where in affect long before the new ACA laws.
I currently have Anthem BCBS, and they always question my need for a Pump/CGM but my doctor supplies them with a explanation of medical need every year with a new Rx.
Thanks for the advice. I contacted my current ACA marketplace insurance (Arise) and was told there are no coverage limits, full coverage after out of pocket max and no specific criteria for getting a CGM.
I have to say that in the first year of having the insurance, their coverage has been better than any previous plan I've had (both employer and self-employed insurance), but I had no claims for durable medical equipment.
I agree how important those bills are and will write to my senators and rep about them (I'm sure my senators will be split and my rep, who is possibly the nuttiest in the entire country, will be against it).
And if you are on medicare…you must follow their guidelines…the insurance is denied…you are out of luck…for T2…even with medical necessity letter…I am so sad for us all who would even pay for pump or a meter out of pocket and ask for the monthly supplies to be covered…pretty much feeling bad about this…but manually doing best to keep on track! I have bcbs of AZ, pay great premiums…but medicare overrules.
