Tuesday May 12, 2009
I was awaiting a call from the doctors office to complete a predetermination form. They called me back this afternoon to tell me they spoke with their Medtronic rep who told them that my request would be denied from the insurance company because they did not cover them yet. I gave the Medtronic rep a call and asked if he had done a predetermination form and he said no. I said well I want documentation that I have been denied from the insurance company and that I was more than willing to do what was necessary to convince them otherwise.
I again asked for a predetermination form and he said there wasn’t one, It would need to be a letter provided by the physician and he said he would work with my physician to obtain one. So with any luck maybe a predetermination letter is finally being created for me. I asked that they send me the letter for my records upon completion. I’ll give them a week before I become a squeeky wheel.
The Medtronic rep asked if I had had any passing out or ambulance rides in the last 5 years due to my diabetes. I began to wonder how bad does my diabetes have to be for them to even consider the system for me. I am a healthy diabetic with only a few of the policy criteria that may warrant a CGMS, they include less awareness of lows, unexpected highs and lows and an a1c above 7.0. I wish insurance companies would realize better medical care through prevention is a better alternative and more cost efficient.
So again… I sit patiently awaiting for the start of documentation. I do expect a denial from my insurance company but this is about my health and the health of other diabetics in Kansas. I am excited about the opportunity to respond and be heard.
Isn’t it frustrating how the better care you take of yourself, the less of a “candidate” you are for more advanced technology? I was looking through all the dexcom paperwork yesterday and it really almost seems like they expect you to be WAY out of control before even considering it… or maybe that’s just how they want to present it to the insurance companies. MM is probably fairly similar - they really want the “worst case” evidence to use to support your case. I know that I felt a little like that when I got my MM pump 7 years ago… I was afraid my insurance wouldn’t approve it because my a1c was too good, but they did
hang in there Michelle, those who go first have the hardest times. I believe that the insurance companies are changing, rapidly for CGM approval. Last year BCBS NJ would automatically deny a first request and approve only after an appeal. I just got my CGM last month, no questions asked, I just submitted a script from my endo. good luck to you!
Thank you Michelle for pursuing CGM even knowing the challenge. I like to think that pressure from people like you will eventually cause a sea change in insurance coverage for CGM. Hopefully CGM will someday be like pumps where insurance coverage is almost universal. The current standard that you must suffer lots of hypos does not begin to address the benefits of CGM to your mental state. The thing about CGM that is impossible for a non-diabetic and insurance company to appreciate is how much peace of mind you get from knowing your current bg at a glance. It’s like going from flying without instruments to flying with an altimeter to warn you if you are too low or too high. I probably wonder about my bg at least once every 30 minutes, day in, day out, year in, year out, for life. ! Keep pushing, and force them to explain why they won’t cover it.
Michelle I had the same trouble with my BC/BS Anthem The paper you want to send the insurance company is call a Statement of Medical Necessity like the one I got off the Freestyle Navigator sight http://freestylenavigator.com/en_US/content/document/FSN-Medical-Necessity-ART10431-Rev-D.pdf you could probably make this do for your CGM When I sent this in The insurance co said There was not enough information on LOws below 50 and highs above 150 so I sent them a list of my high and los taken from my Accu check meter
Good luck and keep fighting I love my freestyle gone from Aic 7.8
Thanks Charles and Sam. Today I found out that I have to write my own determination letter and then give it to the doctor to sign. This will help plenty!
