Has any one with T2 of any type been or heard of anyone being covered by their Insurance for CGM? I’m pretty sure a non insulin dependant T2 would have a difficult time getting coverage, but I’m specifically asking for a friend who is T2 insulin dependant testing 6x daily… Wanted to see what the family says… Thanks
I know this is not encouraging and I’m not T2 so possibly cannot be your friend :), but when I applied with my insurance co for cgms coverage (Aetna) they stated emphatically that only T1 diabetics are covered. I’m a T1, so I didn’t have a problem. But please do not take this as gospel even for Aetna. My Endo told me he has gotten T2 patients approved, but had to provide volumes of patient data regarding overall diabetes management from him for the patient along with a long history of patient daily blood glucose test results including food carbs consumed and of course A1c test data over a period of time. That’s a lot of data and far more than a T1 has to provide, but as you probably know insurance co.'s are tough. But many are finally beginning to take cost/benefit analysis into consideration and especially for chronic illness.
I suggest you contact your insurance co. and just ask them about requirements for coverage, but even if they say no work with your Endo in getting help. If your Endo doesn’t provide help, find another if you can. He/she can help you get your coverage application escalated. You should be able to eventually get your application in front of the insurance medical reviewers who are physicians and they are far less likely to go against your Endo’s diagnoosis and recommendations. We pay physicians to help us. I could speak volumes myself on doctor care issues. Too many of them are in auto pilot mode for patient care and I’ve discovered there really are alternative care givers who actually do care and will go to bat for you for these types of situations.
I wish you the best of luck and don’t give in if they say no at first.
Ron
Ron, for being the only answer I received, it is certainly complete. Thank you so much. I will pass this info on to my friend. I do not know if she has contacted her insurance yet, but betting not since she is still a bit overwhelmed by it all… I will take this information and see if I can’t step up to plate for her until she is stronger… Again, Thank you so much. I hope to hear from others who may have had some experience with this as well…
Right on target Ron. I have BCBS of Texas and the specifically state that CGMS is covered for T1 but for T2 it is considered experimental. I believe that this is based on research studies that have initially focused on T1 with insulin therapy as opposed to T2s using diet/exercise, orals, MDI, or anything else.
SuGaRpAiGe, one point you may try to have your friend make is that as an insulin dependent T2, their treatment regimen is the same as for a T1 covered in the supporting studies, therefor CGMS should be appropriate and beneficial in their management program. At this stage in their disease they are susceptible to the same issues and manage their disease in the same manner as a T1, so drop the nuke and claim discrimination based on cause! 
I will be fighting this same battle in the coming months and am already keeping detailed logs and working with my endo to build the case for coverage.
Thank you, Dan! With what you and Ron are saying, I think I’ll try to help her come up with a plan of action and start preping like you are doing with your HCP. Do you have any specific suggestions? As I stated before, she is still very overwhelmed by all this and is as of yet not as compliant as she should be. She is coming around though & I have been able to share so much of the experinces and support I glean from the “Family”, but when I go with her to her next apt., what should we specifically discuss w/ her Dr. that will help her prep for obtaining a cgm in the future. Also does anyone have any suggestions on CGMs? I have looked at them all, but I cannot do much else so if there are any significant experiences, please let me know…
My plan is to read the studies the BCBS DE policy for CGMS system uses to map my current therapy and goals to those used in the study, indicating a high correlation between them. Keeping a detailed log will document any wide excursions in control and hypo/hyper-glycemic episodes. One thing that will help is to show commitment by monitoring 4+ times daily (I’m doing 7+) and stating your top goals for control & monitoring. Then armed with all of this convince the endo to fight for coverage. It’s pretty much an uphill battle, but by using the same information and studies they (the insurance company) use, you all may see some progress.
As far as a specific system, I’m leaning towards the Dexcom Seven + as I’m going with the OmniPod and they’ll have integration later this year (main benefits: 1 toy to carry around instead of 3 (pump controller, meter, cgm monitor). I based my decision off of going through all of the user manuals, wearing the OmniPod trial pod, and trolling the CGMS forums.
When I asked for specifics I got 'em, huh! AWESOME… Just one thing - translate please… lol! what is a DE policy and how do I help her find it for her Ins?
Doh! Too many “insider” posts! DE is Durable Equipment. Most policies cover insulin pumps and CGM systems as durable equipment (even the replaceable stuff like the sensors, cannulas, etc.).
In my case I searched my policy and there was no mention there of what was coer, just limits. I finally was able to dig up the policies on the BCBS web site. I had to go to the providers section library and look through the policies until I found the correct one. The one I found is here (Agree, sort by section, look under DME for the policy titled Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid ). In this they detail the references and rationale used to make their coverage determination. If you are able to look at this policy, you willfind that T2 are coverd for the short term monitoring that the endo may do, but specifically not mentioned for long-term personal monitoring.
One additional thing I have on my side is that Texas has a law concerning coverage for diabetic equipment determined medically necessary by your physician and approved by the FDA, so I might not have to fight as hard as in other states.
I am a type 2 and i wanted a cgm and I could not get one. My insurance is aetna and they state that a type 2 must show a history of hypos and be insulin dependant before they cover cgms.
I think a good case could be made for a CGM, if the type 2 is using insulin. A CGM is is designed to give a warning in the event of a low BG. I understand that some insurance companies specifically include only T1’s. But, I think if your firend approaches this as an appeal and specifically appeals the denial of a CGM based on a safety concern, he might be successful.
Here is the thing, who ever wrote a plan document is likely not a diabetic. If they were a diabetic, they would have known that a CGM is tied to insulin usage and that type 1 is often confused with insulin usage. I woudl encourage your friend to go for it. first ask for a determination, if he is denied then immediately file an appeal. These are fairly common and the cgm manufacturer will support this effort. Finally, assuming he works, if he is denied coverage, immediately go to his personnel department and tel them of the issue. One advantage of an employer based health care is that the employer is often able to make things happen that otherwise might not. It is important to use that link to attempt to get the issue corrected.
rick phillips
Unfortunately, I think your friend is going to have a hard time selling this unless she is on insulin. Most insurance companies want a whole list of things before they will cover anything. She will most likely need a letter of medical necessity from her doctor, glucose logs, medication logs, multiple a1c’s, etc. It will be a fight for sure (I work in a doctor’s office, helping people get things like this covered) and let me tell you, it’s really tough to do. Good luck!
I don’t know if your state/office does this, but I got my pump as a donation. Perhaps your friend could see if anyone would donate a CGM like if they were upgrading…
What An Incredibly Awesome Idea! I will look into it for her. All of this is wonderful info. I do hope Ins comps. get a clue. I looked into CGMs briefly for my Stubborn T2 recently but quikly gave up on that idea because is healthy though non compliant & he is not on insulin, but my friend is, so I thought I would start over & see what I could find out… We are just gonna keep good records & stay incontact with the Doc while talking to her ins. eventually I am gonna get them to hear the squeaky wheel…
I have Blue Cross Blue Shield of Texas. They approved my Dexcom CGMS immediately and I’m a type 2. They pay 90%, soo I only pay 100 out of 1000 for the unit and 35 out of 350 for a box of sensors. They also approved my Omnipod Pump. Before I had Aetna. They didn’t approve CGMS until 3 appeals or so and it took them a little while to approve my Minimed 722 Pump.
Excellent! Did you have to go through any hoops, hurdles, trials? Do you have PPO? My endo appointment is in 2 weeks so I want to see if I can get one too.
So the trend I see here is in insulin using and that there seems to be a vast difference in coverage availability from ins to ins. Are these recent changes in BCBS Texas?
Yeah, I have PPO. No hurdles. Went to doc one day and filled out paper work and 3 days later Dexcom Rep called w/ insurance info.
I’m not the one to ask. Only been with them about a year I think. First time I ever asked them.
I"m covered with my insurance. I just received all of my equipment a few days ago…haven’t started using it yet. Even my doc was surprised that they approved everything right away. He said that often an insurance company will make you wait about 6 months before approving the CGM. I have no idea why.
I have Anthem Blue Cross of California, am Type 2 on Insulin. They approved my OmniPod instantly with just a simple request from my doctor. No big hoops to go through. However, the CGM was a completely different story. First they denied because they thought that the CGM and the Pump are “duplicate requests”. Then they approved a CGM but if only Insulet would provide. Which Insulet (OmniPod) doesn’t even do. Finally, my doctor REALLY got involved and approved it as medically necessary since I passed out low last year and broke both wrists at the same time. That finally got the CGM approved. Both my Dexcom 7+ and OmniPod are now covered 100% with no out of pocket. I LOVE my Dex and just got my 1st OmniPod in the mail today.
I just wanted to add that I’m covered on CGMS. I’m type 2 have been on a pump for 8 years. I initially had coverage on a individual basis back in 2007, then was denied because of type 2 diagnosis. I recently resubmitted for authorization along with my new pump (my old one was out of warranty and not working) and was approved.
Our health plan is one of the ones available for Washington State Employees I think it’s self insured.
Diana