CFMS Journey - Chapter 3 - DENIAL Letter

Well it finally arrived. I was a waiting in anticipation. I knew the answer would probably not be in my favor, but a girl can dream.

It arrived on Friday 7/3 as I was preparing my house for visitors. It arrived in a nice crisp white Insurance company envelope - Opening it up as if I am waiting to be accepted to an affluent college.

I read…
“All information was reviewed. We have determined the new insulin pump is not medically necessary as the current pump is functioning and the continuous glucose monitoring system is non-covered by my contract and will not be eligible for benefits.” No one is covered by this insurance company they still consider CGMS experimental.

Well there it is, I’ve officially been denied. If I have questions I am welcome to call customer service. Which I plan to do on Monday to get the appeal process going. I am not really sure the best way to proceed, if any of you have thoughts on how to approach this, let me know.

I’m bummed because it has taken 2 months just to get this far, but It’s time things change, If I want this device in the care of my diabetes, this should not be an unreasonable request and should be welcomed and encouraged towards the long term health of a diabetic.

I’ll continue to post as my journey continues.

Okay guys here’s the ususal process and it could back fire - an internal appeal which is call a reconsideration is not really an appeal. You need to get to level 3 which should involve a insurance company physcian "medical director"and your Endo Doc should write a letter to him which which will satisfy the medical necesarry criteria. Now that you documented all this ask and it is again denied ask for a external review or appeal this along with your endo letter should get you where you want to go. The external appeal should be done by an agency outside other than your insurance company. If none of this works and assuming your insurance plan is insured and regulated by your State Insurance Comissioner you file a well documented consumer complaint.

Sorry you have more work ahead. Because of the cost of CGMS you have to make a medical case for the need for CGMS. The ususal ones I have seen would be your enability to feel if you are going low or in the process of trying to get pregnant. If you have documented good A1C’s over a long period of time then it will be precieved that CGMS is mere convience for you. My pump is coming throught the VA and my primary insurance carrier is TriCare - no matter how much documentation I do neither covers CGMS - that why I just ordered a a Animas 2020.

check you drug coverage. I was able to get a CGM with a simple prescription when I found it on my insurance drug formulary (just like test strips) at a time when the CGM was not covered under regular health or durable medical equipment.

Thanks for all the great insight. I called my insurance co. first thing this morning and asked for the requirements to process an appeal, the customer service lady put me on hold for a bit and then came back and said just write your appeal on the back of the denial letter and send it back it… I said “what! no form that needs to be completed”, she said nope. I thought that completely odd and decided to write a more formal letter and faxed the letter and a copy of their denial letter.

I stated that the pump should be approved for upgrade because it will not work with a CGMS and that I should be approved for the CGMS because the CGMS is FDA approved medical devise that is widely accepted in the United States and internationally and the pump and CGMS is considered appropriate care with long term health benefits for Type 1 diabetics.

I’m sure I’ll get another denial letter and I’ll just keep sending them response back. They are going to get so sick of me LOL!

Thanks again everyone, all your ideas and experiences are really helpful.

Okay Darling let’s try this again - you want your Dr. to write the insurance company why you need CGMS. He practices medicine and it is harder for an insurance to refute his request because they don’t practice medicine either and it creates a legal liability to thyem if they go against his wishes.

If none of this works see if your company offeres another insurance company so you can change at next open enrollement. Also the company HR department or your company’s Insurance Broker may have more pull with the carrier than you do. By the way there is a fair amount of literature that a insurance ompany can point to on the accuracy or inaccuracy of CGMS. It has not yet been accepted by the medical community as the best course of treatment for long term diabetis. Sorry I wish it were so. It will probably get there eventually.

Thanks Michael I understood just fine. I actually worked with my doc on the letter. I wrote it and he signed it. I am receiving great support from my endocrinologist and Diabetes Education Director.

I work for a fairly small company and they don’t offer another insurance company and are extremely loyal to our current provider because we are a vendor of the company as well. Many insurance companies are starting to include CGMS in their list of benefits, and that’s good enough for me to pursue. I am doing my part to “get it there eventually” :slight_smile:

Yeah Melissa - that’s a good tip. I’d say even if you “weren’t” hypo unaware - if it helps you in obtaining your CGMS - use that in your next application letter. Luckily, my insurance never refused me when I applied for the CGMS.

I included hypoglycemic unawareness in my initial request, but they didn’t go for it. I have sent in the second letter and we’ll just have to see what happens next. Thanks all for all your great advice. I really appreciate every ones ideas and energy, I feel very blessed by your words of advice and encouragement.