Criteria for Medicare coverage of CGM announced


#122

If your experience indicates a change in all, or even most, Medicare supplemental policies, it will help us. My understanding of these so called “Medi-gap” policies is that their coverage eligibility policy is relatively simple. If Medicare covers it, then they will, too. If Medicare doesn’t cover it then they won’t either. Now they are making a big exception.

Your case with your Medicare supplemental policy changing a fundamental eligibility policy is significant. I hope other insurers follow their lead. I’m curious, however. What do you think motivated them to make this change?

Congrats on your new CGM!


#123

As Medicare goes, so does private insurance. If you closely look at private insurance policies they closely mirror Medicare. Even though Medicare has not gotten it fully implemented, it has changed policy. And so as Medicare goes, so does private insurance.


#124

The way my supplemental (not Advantage) plan works is that if Medicare considers it a covered benefit Medicare will pay 80% and my supplemental will pay the remaining 20%. Just as @Terry4 stated. But there is some sway in that rule, I’ve noticed, whereby if BCBS sees a benefit as so worthwhile that they want the patient to have access, they will cover the Medicare denied service or benefit up to the limits of the BCBS policy before it flipped to a Medicare supplemental policy. I can only guess this has to do with cost/benefit analysis.

I also have an endocrinologist who really wants me on a CGM again. I’m kind of strict about control and if she can’t talk me into easing up a bit then this is the next best thing to her way of thinking. But I really don’t know if anyone even reads those appended notes.

My son works in Silicon Valley. There they talk about something called a “Moon Shot” whereby you are pretty darn sure something will go down in flames but on the minuscule chance you could succeed you go for it. This was a Moon Shot that landed. :wink:


#125

Questions???

Medical supplier(not Liberty). What supplier?
Did you say your BCBS supplemental contacted you first?
Have you actually received the Dexcom G5 system?
Quite frankly I’m a tad confused concerning statements such as your BCBS supplement will pay 100% of cost. Do you actually know the cost amount the medical supplier will bill Medicare & your BCBS plan?


#126

It is the medical supplier that works with my supplemental BCSB policy. BCBS did not contact me. I asked my supplier to request an authorization through both Medicare and BCBS and the supplier then requested an Rx from my endo. The next call I had was from the medical supplier sayng Medicare wasn’t covering CGMs as yet but my supplemental would cover it, in full. I didn’t ask why or how much. It has shipped and I didn’t need to sign an ABN.

In the past my BCBS policy paid, in full, for my insulin pump and supplies, diabetic testing supplies and a G4 CGM. But that was all before turning 65. When I turned 65 this BCBS coverage changed from full to supplemental and at that point Medicare wouldn’t cover a CGM and BCBS denied coverage as well. I have no idea why this new request for coverage was granted. I haven’t received the G5 yet but I’m told UPS will deliver it Thursday or Friday.

I hope I answered your questions. If details are missing it’s not an attempt to obfuscate but rather a sensitivity to the fact this forum is open and indexed by search engines.


#127

My complaint for non-response has been escalated to Dexcom senior management as we were informed by phone yesterday. Not sure what this means, but I’d really like to have ALL our paperwork that was submitted to Liberty Medical returned to us so we don’t have to go back to square one? We furnished LM everything they required; (paperwork wise) to meet the CMS requirements in order to get a G5 CGM unless that may have changed in the past few weeks?


#128

Have you seen in your BCBS records that they have actually paid for your CGM? I hope that’s the case. :grinning:


#129

Another article on what’s going on (or not going on) with Medicare G5 reimbursement. http://www.ajmc.com/focus-of-the-week/0517/medicare-coverage-for-cgm-caught-in-regulatory-limbo


#130

@Laddie, I have not received a statement from BCBS as of yet. Those tend to be quarterly so maybe I’ll see something in July? I’m a skeptic at heart and asked, twice, if there would be any co-pay, and I was told “no” that the CGM was pre-authorized and covered by BCBS. I then asked if I needed to sign anything like an ABN, which is pretty standard when Medicare is involved, and she said no. I’ve had zero billing issues with this medical supplier in the past. So going forward was a risk I was willing to take. My G5 arrived yesterday.


#131

Lots of people have been receiving G5 supplies from Liberty. Unfortunately they had to sign that they would pay if Medicare did not. As far as I know Medicare has not yet approved those orders. I withdrew my order just as they were about to ship because I am new to Medicare and still have some supplies. I figured that I did not want to start my Medicare life with having to immediately file an appeal. Of course my first order of pump supplies was denied, but the supplier is working to get that changed.


#132

Laddie, FYI the attorney mentioned in the referenced article - Ms. Debra Parrish was our attorney in our fight against CMS for the Omnipod Pods not being covered by CMS because they do not meet the definition of Durable Medical Equipment (DME). Ms. Parrish was recommended to us by your friend Sue, and Debra is a great lawyer that is willing to help people afflicted with diabetes, and their legal battles with CMS. If the tudiabetes community could garner enough support maybe a class action law suit could be our next course of action to force someone’s hand on this matter?


#133

Clarafication: State of residence? Specific BCBS plan? Most importantly, medical supplier name & phone #? Thank You


#134

I’m certainly not clear of all issues at this point. My initial shipment included the G5 receiver, two transmitters and one box of sensors. So the very first time I need to call to obtain sensors, only 6-8 weeks from now, I’ll be anxious all over again. I too called Liberty and asked my application be cancelled. I also asked for an email confirmation this had be done. Still waiting on that last bit.

Thanks for all the clear and accurate information you are posting here. I’m a huge fan of more light and less flame.


#135

Please decode “ABN.”


#136

Please provide specific info requested. Medical supplier & phone #. In regards to ABN(Advanced Beneficiary Notice). Nothing more than a CYA form which I completed for both Dexcom & Liberty. In response to your call from medical supplier “based on your statement that your BCBS supplemental carrier stated they would cover G5 100%” is without question very unorthodox. Again whole process is certainly out of the ordinary for coverage & generally unknown to occur for a medicare participant.


#137

To be exact. Have you agreed to be confidential on this info?


#138

Sorry. ABN is an acronym for Advance Beneficiary Notice of Noncoverage. It is a form stating that if Medicare doesn’t pay for the ordered and delivered supplies the patient accepts responsibility for the amount due. This is what CMS calls their form but often suppliers will substitute a generic form saying the same thing when dealing with other insurance companies.


#139

Thank-you @mremmers and @JDP_68_13T1. While I’ve been on Medicare for a few years, that acronym was not part of my vocabulary.


#140

I am careful what personal information I place on a very public forum. I’ll not be discussing the specifics of my insurance coverage, doctor or supply chain. Sorry if you find this unhelpful. I have no idea why a Dex was approved this time after being denied G4 supplies two years ago. But my thought was that someone here may want to likewise take a chance and, despite being rejected earlier, give it another shot with their private insurance. That’s the sum total of what I did.


#141

Backdoor approach hey. I can understand your situation. Don’t wish to unlock the backdoor. Had the same thing for a few years but was required to go with Medicare & supplement(BCBS) prior to 65 as private insurance became to costly. Even with paying for my G4 supplies the medicare way was a great deal money wise.

BTW, obtained Dexcom G5 from Liberty on 3/27. Mailed on 3/21 via mouse delivery.
Due ambiguity by Medicare on payment, box received remains unopened as it is less money for me to continue to use G4 at present time. I use the G4 “therapeutically” to use MAC language adopted as of April 2017 and essentially would only begin to use G5 when medicare ceases the stalling on coverage.

Don’t you just love Medicares evolving change in language for CGM systems. Prior to last year CGM was classified as precautionary. At this time that has changed to adjunctive & non-adjunctive with the added sub categories on therapeutic & non-therapeutic. So until medicare can resolve their own head spinning, G5 coverage is on a case-by-case basis.