Criteria for Medicare coverage of CGM announced


#101

I’m sorry to read this, Laddie. It’s curious that their target date for discontinuance of their G5 supplies to Medicare beneficiaries is May 28, four weeks in the future. I wonder if that means they have some shipments already in the pipeline or if Medicare requires a four-week notice in this instance. I wonder if Dexcom has stated anything publicly today.


#103

Thanks Jimbo … and there is really nowhere to go with Liberty at this point. IT’S CRAZINESS!

I too have done the appeal process. I appealed my Medicare CGM decision up to the 4th level of denial, where the ALJ even said that I proved medical necessity and that it was cost effective. I asked Dexcom to support me in suing Medicare … they refused, saying they were close to getting coverage … and that was over 5 years ago!

I also worked with Insulet and their corporate attorneys in appealing Omnipod claims through pharmacy benefits. I got to the 3rd level of denial … then Insulet let it drop because “there was a change in administration in January”. Huh? I reminded that it doesn’t matter who the president is, we still have T1 24/7. Anyway, the window to file a 4th level claim ran out. I was still reeling from that!

Has anyone discussed a class action lawsuit for discrimination? ACLU?


#104

Just spent 90 min. on phone initially w/ Dexcom who transferred me to Liberty. I could spill the whole thing to the forum here, but I’ll just sum the G5 matter this way. HOLY SMOKE my head is spinning from the nonsense conveyed by both parties. Everything has been placed on hold if one persists on using Medicare. Only viable option at present is to pay out of pocket(i.e $599 for G5 receiver, $599 for transmitter kit[2], & $349 for sensors[I month]) from Dexcom. Dexcom will provide detailed invoice for purchase & then you can complete CMS form 1490s to file claim w/ Medicare. This requires you to provide complete info as to your status requiring the item in question. IOW’s you need to get an “unknown # of ducks in order” to be successful for Medicare to reimburse you??? I ask myself one question regarding amounts quoted by Liberty & Dexcom. Liberty says G5 system is $1025 w/ Medicare. Dexcom says private pay(only for those caught in this dilemma) is over $1500. Even looking at what I stated & presuming one is successful w/ Medicare claim, there is still at least a $400 difference. How does one resolve this??? Will the dust ever settle so patients can be provided required & adequate medical supplies. Trying to stay on top of ones Type 1 is difficult if supplies to maintain stable control are lacking. Sources conveying message that they care is simply a lie…


#105

Joanne,

I think your idea of a class action suit is a great one, that is if we can garner enough support here on tudiabetes from the members? Not sure if the ACLU would help those of us out in this situation or not? I know from experience that writing to our Congressional Representatives doesn’t help much either as I always receive the same boiler plate replay that its Obamacare’s fault, and they are fighting hard so that Medicare for seniors will not go away. This is always the “standard answer” when there’s an Administration’s change.

Just yesterday I sent another email to both U.S. Senators - Susan Collins (R-ME) and Jeanne Shaheen (D-NH), the Co-Chairs of the Senate Diabetes Caucus, because they both recently sent a bipartisan letter to Centers for Medicare and Medicaid Services (CMS) Acting Administrator Andy Slavitt urging him to provide Medicare coverage for lifesaving, clinically appropriate treatment for diabetes. Senators Collins and Shaheen have consistently fought to increase funding for diabetes research and to promote better health care for people with diabetes. In my email I asked them to push for the OmniPod Pods to be approved by CMS since the Dexcom G5 was approved in January. I’ll wait for their response, but doubt that I’ll ever receive one since I’m not one of their constituents.


#106

@Joanne11 and @Jimbo31 – There already is an ongoing class action lawsuit against Big Insulin and it’s being conducted by a firm that took on Big Tobacco in a class action lawsuit and won, a lot.


#107

I’ve been writing letters for as long as I can remember. In the last few years, for devices, it’s like talking and no one is really listening in Congress, as long as they have their special health insurance benefits. I would be interested in the option to look at this as discrimination.


#108

Got same letter from Liberty as Laddie. Liberty has told me “everything is on hold” . Same response from Dexcom. Liberty letter explicitly states they are withdrawing from the G5 process… There is no source available for the G5. No supplier or manufacturer is willing to deal with the burden which Medicare is clearly unwilling to clear up. Sorry folks but we the patients are SOL. Doesn’t it feel great to always be teased about a situation that does provide better control for a T1D individual and then told it will be available “if you follow the yellow brick rode”.


#109

I’m currently listening to Dexcom’s Qtr 1 conference call. Timing pertaining to those awaiting Medicare covered CGMs is to be addressed in this call.


#110

TiaE: I suspect it will only be some positive toned Flim Flam but bottom line no new developments. If your on Medicare your not getting the G5 system. As for supplies for G5 already in use, probably out of pocket pay requiring independent claim filing w/ Medicare without much chance of success.


#111

JDP_68_13T1,

As you and I both pointed out in previous postings above, anyone can still get the G5 CGM from other suppliers around the country who carry it. However, you will have to pay out-of-pocket first then submit CMS Form 1490S, and deal with CMS by correctly filing ALL the necessary paperwork they require in order to obtain the 80% reimbursement. Should your Form 1490S be denied by CMS then you will be out what ever money you paid in ordering the G5, and will have to go through CMS’ FIVE level appeal process to see if CMS will rule in your favor.


#112

I was called away from my desk so I missed a major portion of the conference call. I did catch part of the conversation pertaining to the Medicare approval. Dexcom apparently didn’t expect approval so soon. There was talk about the potential market in Medicare recipients. Apparently, info for 10,000 Medicare recipents is already in Dexcom’s systems. I had to leave just as they began discussing timing. Seeking Alpha posts transcripts shortly after the calls. I’ll post a link when the transcript is posted.

Im not sure if sign up is required to view the transcript. It’s a pain to copy/paste articles from my phone, but ill be happy to do so from my PC tomorrow.


#113

I’m about to wade into speculation here so, fair warning to those who dislike such folly. :wink: I think we all got this email today around noon. The one word that jumped off the screen and gave me a “gotcha” moment was “political”. Every single person I know who works for a government agency or as a government subcontractor is dealing with policy changes - rollbacks. Especially policies, benefits or programs that were initiated and passed during the last 2-3 years. It’s all up for grabs. I wouldn’t be shocked to find out CGM’s for Medicare beneficiaries are dealing with the same spin. Backward spin. A freezing of benefits at best. I think at this point in time what is happening would be exactly what we’d see - confusion and rules changing or being withdrawn. I’m starting to think Liberty is just an unfortunate victim in a much larger issue. Sure hope I’m wrong.

http://view.dexcom-email.com/?qs=4c913d8d8b78eb64f8511250ddf83aa8f4bbb0becdb2368f2b8c9d3d6e830658bd598ccb80506a0e13b222698556aa0515b7ce6cb96ce3286763523a5ceb58c5


#114

Thank you for posting your email from Dexcom. The word, “political” jumped off the page at me, too. All along I was wondering how much a change in administrations would impact this new policy. It can be difficult, from our distant perspective, to see a difference between a bureaucratic startup ineptitude with a new policy and deliberate maladministration to jamb a monkey wrench in the process.

Dexcom staff are closer to this situation and their use of the term, political, to describe things is unsettling. I’m hoping my suspicion is ungrounded and the wheels of the bureaucracy will start turning soon and place CGMs into the hands of people who need them.


#115

Mary, We are Still waiting for the referenced email from Dexcom that you received? I wrote to my contact @ Dexcom after reading your reply here, and have not received nothing, nada from him yet? Looks like you have some special clout w/Dexcom being a past Dexcom G4 user.


#116

@jimbo31 I wish. No special access for me. I must have gotten onto one of their lists for updates.

But yesterday, as I was thinking about this whole issue, I kept coming up with the same question - what tipped the decision to give Medicare recipients CGM therapy? I suspect is has everything to do with cost/benefit analysis. Are CGMs keeping people out of hospital ERs and ICUs? Because that’s a very expensive event. And maybe the technology is getting less expensive or at least Dexcom is offering a palatable price per unit on a Medicare contract? Don’t know the answer. But if the Medicare bean counters are buying in maybe private insurance is too?

Two years ago, when I went on Medicare and had to give up using my G4, my BCBS policy switched to a supplemental policy and denied CGM coverage. But maybe their gatekeepers have likewise come around to seeing how CGM therapy can be cost effective? So I’m giving it another try and have applied, though my BCBS supplemental plan, for full coverage of a G5. I’m probably dreaming but thought I’d see if the landscape has changed. I’ll keep the group updated. Don’t hold your breath.


#117

Mary, I love your analysis here! But the truth is, that I don’t think Medicare really cares that CGM’s, or Insulin Pumps are keeping people out of ER’s & ICU’s. However, Diabetic patients can truly attest that these devices really do help manage their disease as WE all know that they can. You being a Medical Professional know these things first hand as you saw and lived it in person. CBS - 60 minutes did a segment not so long ago where hospitals, and ER doctors are rewarded with bonuses for admitting Medicare age patients. These hospitals set quotas so they can bill Medicare for the extra revenue. The hospitals would much rather admit Medicare aged people than non-medicare aged people so they won’t lose out on this revenue. This is where Medicare IMHO lacks the proper watchdogs to keep costs in check. Basically, these hospitals are committing fraud, and getting away with it.

You and my wife are close to the same age, and we went through exactly what you are saying as we also had a BCBS policy that paid for my wife’s Omnipod - Pods, but at age 65 that all stopped because just like your G4 CGM, Medicare said this was NOT Durable Medical Equipment (DME) because they are disposable. We argued through 4 levels of appeals before CMS that they are wrong, in that devices such as these should be considered Supplies, but CMS still won’t buy into it to this day. ONLY Congress can change these rules & laws!

I wish you the best in trying to get your CGM covered through your supplemental plan, but unfortunately, I think they may tell you that if CMS won’t cover it, then by law neither can they cover it. We went down that road with the Omnipod Pods, and that is what we were told when we wanted to buy a supplemental plan through BCBS. So as you said, “don’t hold your breath” or God forbid you may be admitted to the hospital to help them meet their Medicare quotas.


#118

@Jimbo31 I spent a lot of my life in hospitals but have almost zero experience with the ins and outs of billing so I’m not qualified to comment on Medicare/Insurance fraud issues. I’m sure fraud exists and there are very stiff penalties when discovered. Hospitals have lost their accreditation over extreme patterns of fradulent billing.

Medicare has a strong desire to make payments based on costs linked to outcomes. If a treatment is cheap but doesn’t work it won’t be approved. If a treatment is expensive but audits show it will save health care costs over time it has a good chance of being approved. It’s all about the data and the bottom line. Unless politics comes into play. That’s the wild card.


#119

Thank you, all, for your contributions on this topic. I’m so glad I found you guys! This is my first time posting so near with me please. I miss my Dexcom and have been jumping through hoops too. I’ve been bumming because I feel like I’ve been locked out of CGM technology just because I am on Medicare. I am a new mother dealing with health challenges such as type I and drug and alcohol recovery. Dexcom helps me control the numbers! We all know how important this device is. I’ve been moved to write to the Diabetes caucus seeing that congressional support is crucial to our health. Eek. The politics of health!! At this point I’m not sure what I should do after being notified by liberty of their decision to cease distributing Dexcom supplies to Medicare patients. Buying outright is not an option for me at this point due to financial constraints (disability is my source of income and a home health aide job twice a month or so)…I want to continue to improve my health and maintain my recovery for my family and be the best daughter, partner and especially mother I can be… do I work with Dexcom or Medicare? Or discrimination lawyers? Do we band together and take to the streets? I’m so agitated my blood glucose has risen steadily brewing over this subject!


#120

I’m not inclined to Class Action Lawyer Up at this point. I’d give it six months then revisit what next scenarios if Medicare approval and delivery doesn’t come through. I pick my battles carefully.


#121

Well, it would be an understatement to say I’m surprised, but I heard back from my medical supplier (not Liberty) and my supplemental BCBS will cover a G5 system, in full. It shipped today and should arrive at my door in 3-5 days. Medicare “isn’t covering these as yet but your secondary insurance will”. This is the same insurance that denied me continued coverage of my G4 when I turned 65 and went on Medicare. So, I have no way of knowing why this has been approved, but something has changed. Maybe the G5’s specs? Or data showing they are cost effective?

I would urge others to give their secondary a try, again, if previously denied. Now, if I get the phone call tomorrow saying, “Just kidding.”, I’ll report back.