CGMS - Insurance - Alice in Wonderland

Following up on a recent post about the increase in cost for Dexcom sensors after Dexcom made a deal with Blue Cross for coverage, I called up Dexcom to check on the prices and coverage.

Sure enough, Dexcom and Blue Cross made a deal and the price went up. But that’s not what gets weird.

Turns out my Medical Necessity letter has expired, so Dexcom needs a new one from the doctor and needs to get preauthorization from Blue Cross before BC will pay it’s share. They also need 30-60 days of BG readings. Okay, Fine, No problem.

Get a call from the Dexcom Rep asking me if I have more readings that show more “Lows.” BC apparently has some threshold of lows it needs to see before it deems the CGM ‘medically necessary.’

So the upshot is that I may not have enough lows to qualify.

In other words, because the CGM is working and helping me prevent lows, it’s obviously not medically necessary. Because it’s working, I don’t need it? So are they next going to deny coverage for my insulin because it’s working to keep my blood sugar down?


Another way to look at it is that I have to prove that the CGM isn’t working before they’ll pay for it.

Go figure.

That’s ridiculous, Terry. Do they want you to disconnect for 30 days, chart the rapid decline in your control, and then submit???

I thought I heard it all! That is insane.


Would going into a hypo coma satisfy their requirements!

Yes, it seems that lows are all the insurers care about. Which is really ironic, given that highs are what cause all the damage to our bodies and newer research suggests rapid swings are a bigger concern than we previously thought. From my discussions with various CGM sales reps and PWDs who have been successful in getting coverage, “frequent, serious lows” and “inability to sense lows” are the magic code words that help applications for coverage get approved.