Cgm users

CGM users,

I’m having an EXTREME amount of trouble with my insurance getting a new transmitter for my cgm (it’s out of warranty)…I rely IMMENSELY on this cgm every day to help watch my sugars and determine patterns to see when I might need more insulin/basal (am semi-new to pump). Have a past of EXTREME dropping sugars, either from exercise or after I eat where my bs can drop up to 30 points a minute!! VERY scary and dangerous…I also use cgm to watch bs’s at a job/school when am on feet all day, as exercise effects have always carried over for hours too.

I’ve also been very sick the past 1.5 yrs, with several rounds of chronic bronchitis, lasting 3 months each, several bouts of kidney stones which cause severe pain which rises bs, chronic idiopathic hive outbreaks which cause immense burning, itching and numbness in body. All of these have prevented me of really caring for my sugars properly and getting basically ANY exercise. But even when am able to take a 10-15 min walk, that can either cause bs to go down, not at all or go up! Took a 45 min STROLL recently and took NO insulin (for correction, and took half the food insulin needed and did half basal for 2 hrs)…BS still went down 100 pts! So if I had taken an extra 5-6 units for bs? (was in 300’s to start but wanted to do a test with the exercise and no insulin)…With the extra 6 units, it would’ve went down an EXTRA 180 pts!? Would’ve ended up low)…

So diabetes is always taking more or less when you think you will be exercising or not, and never really hitting the mark and have your bs’s be good when finished…It’s like hitting 200 moving targets??? It’s sooo frustrating…anyone else have this? So my sugars run in the 200’s most of the time. Of couse I’d like them better but have had many obstacles along the way…Now to the insurance…

The insurance has denied my case 3 times, and closed the case several more times, all for different ‘reasons’…The first time they said they didn’t have an ‘out of warranty’ statement from the transmitter and no letter from my dr. stating the benefits of the cgm. (My dr. had already sent a letter and the company that does the cgm said they sent the out of warranty note).

So I called both my dr and cgm company to have them resend the info. They did. The next denial said they still didn’t have a letter from dr. stating the benefits nor any clinical indication I have benefit from the cgm. Now I had sent in bs logs and while they haven’t improved greatly, I havebeen able to get them into the upper 100’s/lower 200’s, (which is big for me). CGM company said they had never heard of an insurance denying something based on what bs ARE, they just want to make sure you are checking bs besides using cgm. And they said the bs logs I sent in to them were sufficient logs.

So I call insurance, dr. and CGM company again and have them all send info again. (Been on phone almost everyday for 4 months with all parties). Now insurance said case was ‘closed’ b/c they did not ‘receive any of this documentation’ or ‘receive it on time or at the same time’…(these were 3 diff times of case being ‘closed’)…Now ALL the info was sent to them on time because I made SURE of it and called nearly evey day and several times/wk.

NOW they re-opened case with all the info sent again, saying it will prob be denied b/c all the info is the same it’s always been since 4 months ago (even though my dr. wrote another letter)…Got a call yesterday saying it was denied AGAIN, because my ‘sugars have not improved’ and am not showing testing bs 4 times a day, only 2.5 times a day??? The logs I sent showed 4+ x/day and my DR. wrote am testing frequently!! HOW can the insurance do this?? Does this sound like the run around or what?? Your bs shouldn’t have to be ‘perfect’ or even ‘good’ for you t get a device that helps EVERY DAY?? This is the ONLY thing that has let me get bs down a bit b/c of severe crashing, I resorted to noteven taking corrections…NOW, I am taking corrections B/C i have cgm to monitor!! I actally eneed up in ER once b/c crashing so much. Also if I walk AT ALL in the COLD, I can get severe crashing…It went from 280 to like 110 in 3 MINUTES of walking!! Now wat if my bs was already 200 when I started walk? It would’ve been 30 in 3 mins?!! VERY DANGEROUS…

Insurance also denied/closed my dr’s peer-peer review on phone to try to overturn denial b./c 'dr waited too long to call, called 45 days after the 30 day window of denial"…My Dr. office said they weren’t aware of this denial so they didn’t know to call, and only found out because I CALLED insurance to see what was going on…

My dr.'s office said they’ve given like any reason under the sun to deny and I said we couldn’t keep up with their demands and even if we did,they would’ve said no b/c of my ‘non benefit’…even though every piece of info indicates benefit b./c its helping prevent dka episodes…(have also had some dka due to bad pump sites where cannula bent and not getting insulin…only way to tell this is to watch cgm and bs rising!! Then i know to change site) THIS IS HUGE. There are SOO many reasons why I need this, esp. on a job where i"m on my feet running around all day and not able to check sugar…

Now I have to go write an appeal myself and HOPE AND PRAY it will get covered!!! ANYONE HAVE AN ISSUE LIKE THIS BEFORE???

Sorry about all that.

What insurance company do you have?

Yes, I had similar problems with my insurance. The way I finally solved it was:

(1) Get ahold of the insurance company’s “medical policy” for coverage of CGM and

(2) send an appeal that lists exactly how you fit that medical policy.Keep it brief and factual. Include copies of everything that supports the claim (BG logs, clinical notes from Dr visits, etc).

(3) call and keep calling until you get somebody on the line who will spend the time to read the appeal letter and tell you who to talk to next, what dept will review it, etc. In my case, they kept “losing it” and finally I was given an email address that went to the person I was talking to. I was able to confirm that it was received and reviewed. That was the crux move and coverage came quickly after that.

After all that, I am thinking about self funding CGM next year…the way my insurance works, the 3rd party supplier marks ip the prices so much that my 20% copsy is almost the same as Dexcom’s full retail price! So the insurance does not really do me much good for CGM supplies.

But even if you have to pay the inflated copay at least it would go towards your deductible right?

Yes it eats up the deductible…I’m hoping I can find a higher deductible 2018 plan for hopefully much lower premium and will crunch the numbers if such a plan exists. Might be a pipe dream!

Neighborhood Health Plan in Mass

i live in MA and had the same plan many years ago. you need a medical of necessity letter to be submitted. this will show that you need it! im surprise that they arent covering it but again the letter. resubmit the testing that you have that shows 4 times a day, etc. this should help get you the CGM…also have something from the ER that says you came in because of your sugar levels and you need to monitor it so you dont end up in the ER again

Hi there,

My Dr. has submitted 2 letters of necessity, both of which didn’t help. The insurance keeps coming up with different ‘reasons’ why they are denying, which we can’t keep up with. Will try to get ER record…I just don’t think anything will overturn denial, and I’m not doing well with my sugars, but know I will do much WORSE without cgm, with the past I’ve had. :(…This is such an infuriating disease. Thanks for reply.