Denial Decision from Excellus BC/BS

I have been on the Dexcom Seven Plus for one year and three months. The original system was covered by BC/BS Illinois. I have since picked up Excellus BC/BS insurance from my former employer, retired, and dropped the BC/BS Illinois through my husband. Excellus has been paying for the sensors for the past year. After being on the Dexcom for a year, I sent Dexcom a one month CoPilot report that showed that I had 4 blood sugar readings in the 40’s, they contacted my endo and got what they needed,and they got the OK from Excellus to provide me with a new system, because the original system is out of warranty. Today I got a denial decision from Excellus saying the services are not medically necessary and are ineligible for coverage. When I go hypo during sleep, my husband needs to give me orange juice or maple syrup to bring me back. I plan to appeal this decision. Any suggestions?

Write a very detailed letter to your insurance company describing some of the lows you had pre-Dex. I think my letter was 3-4 pages. Describe the difference between having the Dex & what it was like before. Even though you have had lows in the 40s, they are not as severe as what they were pre-Dex. Didn’t you have some 911 calls also? Put that in.

Good luck - I worry every time I go to get supplies.

Kelly, you’re correct, good memory, I stopped breaking once, my husband called 911 and I ended up in the ER. And another time he called 911, I woke up with the medics surrounding my bed, but I didn’t go to the ER. I’ve had countless nights of convulsions while hypo. Now the DexCom usually wakes up either him or me in time to treat it before it goes too low.

When are these insurance clowns going to realize that we wouldn’t need the DexCom if we didn’t have life threatening hypo’s??

Thanks for your suggestion, I’ll get started on it tomorrow.

I thought you did but wasn’t sure - my memory is not what it used to be!

They probably think it is cheaper if we died. When I did my letter, I told them if I did not live alone and someone was calling 911, I would have made numerous trips to the ER because of the lows.

I will keep my fingers crossed for you!

Thanks Kelly. I called BC/BS this morning and requested to get the process started for an appeal. I am in the process of writing a letter of appeal to them, listing all the incidences of low blood sugars that resulted in 911 calls, trips to the ER, etc, including the time I fell into my glass topped coffee table. I am also going to send them my Dexcom report, as well as my CoPilot report of blood sugars. The Dexcom report shows several times my blood sugar was <40. I have a call to Dexcom and my endo’s office, hoping to hear from both to see how they can help the process. Like you I wear my Dexcom in my Spibelt and only remove it when bathing or when necessary. I just got a new Spibelt with two pockets so I can wear the Dexcom and OmniPod PDM on me. I went grocery shopping yesterday, didn’t bring the PDM and ate there and wasn’t able to bolus until I got home. Not a good thing!

Sue,

Hey, I wish you luck in taking on the BC/BS… Someone else had posted something similar to this and had some good info for BC/BS…
http://www.tudiabetes.org/group/dexcomusers/forum/topics/a-few-resources-for-the

Good luck!

Dexcom might have some sample letters that you can send. When I was originally denied, I was trying to get the Navigator and Abbott sent me some. Most of it wasn’t useful but I think I did get about 3 sentences that helped.

That is one advantage of a tubed pump - although if you leave home without it because you took if off to take a shower & forgot to putit back on, you would really be in trouble!

I haven’t had my pump on for a little over 3 weeks now since it broke. My brother is coming in and we are supposed to all go out to dinner so I will probably put it back on for that.

Kelly, your pump broke? Did they send you a replacement?

The CDE I had at Joslin has a tubed pump because she likes to have it attached like yours.

I spoke with the nurse at my new CDE’s office. When I told her the Dexcom is a replacement because the original is out of warranty, she asked if the original is still working. I said yes it is, and she suggested I return the replacement to Dexcom and continue to use the original. Also since my last A1C was 6.7 she said I have excellent control and that would be a reason why the insurance would not ok a replacement. I printed out my Dexcom and CoPilot reports which show 6 readings below 50 in a 14 day period. I am going to send my letter to BC/BS and hope for the best.

Thanks Kaayle

It broke in Jan & they replaced it then the replacement broke in Mar. They replaced it but they sent a refurbished one - I wasn’t too happy about that since I was only using both of them for a total of 8 months. It took 2 weeks, but they finally said they would give me a new one for this one time. It is still sitting in the box!

When mine was turned down, my A1c was in the 5s. I pointed out that I was passing out alot and that brought my A1c down. You have lows almost every other day so that should qualify - you also know there would be more if you didn’t have the Dex (I know you know that, I am just being rehotorical!).

Hi Sue,
I was able to avoid an appeal because of getting HR from GM involved. They were able to get someone from BCBS to get involved by phone and she worked to get both the Dexcom and the Omnipod covered for Melissa. A couple of other people from TU were fighting as well because this was a new policy for GM and we have no choice now like we did before to choose an HMO.
I chose to focus on the fact that they were denying something that another insurance company had paid for and was working well in avoiding the lows. Make sure to stress that you cannot feel your lows and do not wake up. I told her about dead in bed syndrome. I think that is when she decided that she needed to make this happen for us. What kind of money would we be talking about if something happened to her at night because she was not wearing a sensor?
They were calling the Omnipod a disposable pump and were not willing to cover the supplies for that either. I made it clear to them that Melissa was used to this pump and that she would not be able to use another pump independently safely. That made the case for us, but they also allowed it for others. Now both items are to be decided on a case by case basis for this policy. Keep it in mind that you may have another fight on your hands if you need a new PDM. It is crazy that they were willing to pay for a new traditional pump rather than just the supplies for the Omnipod.
I really think that they will only pay for them if you are willing to fight, so be willing to take it all of the way and I am sure that you will win! Most people don’t bother to fight, and that saves them money. Good luck and keep us posted.

Mary, I called them yesterday and told them I want to contest their denial, and it has been started. I wrote a pretty detailed letter explaining my lows, and printed out Dexcom and CoPilot reports which showed 6 readings <50 in a 2 week period, mostly at night. I called the hospital and asked them to send me a detailed printout of when I was brought to the ER and treated in 2006 for hypoglycemia. I talked to my new endo’s nurse, and she was no help, she asked me if the old system is still working, I said yes and she told me to send the new unit back. She said my last A1C was 6.7, which is “excellent” and that’s why they sent me the denial. She said their patients use the Minimed and if I want to go on that they will work with me. She was a huge help-not! I talked with Dexcom today, they haven’t received the denial letter yet, but the woman I spoke with told me that they will contact BC/BS to find out what they require and will give me a call. I’m not surprised this happened, one of the teachers I used to work with had her CGM denied after one year, but she seemed to accept it. Not me, I won’t go down without a fight! You brought up some good points, thanks.

We just started with a new endo that is pro Minimed too. Makes me angry that these endo’s choose one pump to favor. It is not them that has to wear it and the choice should be up to the patient. That is just stupid that an A1c of 6.7 is considered excellent, especially since you have a problem with LOWS! I also would have questioned why they would work with you to get you a Minimed, but your A1c is too good to get a Dex?
I wouldn’t count too much on Dexcom to help you though. Neither Dexcom or Insulet helped me at all. I only contacted the rep from Dex though. He offered to get me in touch with someone else that fought and won, but he never followed through.

Mary, do you remember me posting on ADA that my endo told me not to strive for better A1C’s because the ACCORD trial proved that it didn’t make a difference? I was lamenting that I had gone from 5.9 to 6.7 when she told me that.

Funny thing about Dexcom, when I call they want you to leave a message and someone will call you back the next day, then they don’t call back. When I called yesterday, I wasn’t going to play that game again so I went to customer service, got a real person, explained the situation, and she sent me to someone else, who said she would pass the message on to the next person, etc etc. I think I read somewhere that they haven’t made a profit yet, so I wonder how large their staff is?

The denial letter stated that in order to be approved for the CGM you have to be on an external pump, and if over 18, must have hypo’s resulting in a profound degree of cognitive dysfunction which requires external assistance for recovery. The woman at Dexcom assured me that they had submitted this information to BC/BS in the endo’s Letter of Medical Necessity, but wondered if they didn’t look at all the information submitted. I think they chose to ignore it, hoping I wouldn’t fight it.

My son Steve thinks that the Republican Tea Party is to blame, wanting to cripple Medicare and Medicaid, which will influence the insurance companies to deny services to one third of us. Like Kelly said, they just want us to die.

Yes, I do remember that. I haven’t looked at the study, but I just find it hard to believe. It would be really great if it were true, but it just doesn’t make sense to me.

Mary, I’m sending out my appeal letter today, wish me luck. I had been waiting to get a copy of the bill from the hospital back in 2006 when I was treated in the ER for a severe hypo that hubby couldn’t bring me out of, finally got it in the mail Saturday. My son Steve is here for Easter and he proofread it and made some changes. I received an Acknowledgement of Internal Appeals or Grievances in the mail, that said," Please be advised that no action is required on your behalf." They darn well better look at my letter!

That is the right attitude to have Sue. You just don’t take no for an answer and especially with that proof of what can happen, I don’t see how they can turn you down. How long do they have to respond, 30 days?

Mary, they have 60 days to respond. I’m hoping it doesn’t take them that long to see that the Dex will be beneficial to continue using.

I disagree with most of the suggestions being made here. Insurance will, generally, deny anything it can – within limits set by Courts, Juries, Medical Boards, and actual Law. For better or worse, we’re all in this together: If we continue to let Excellus get away with these denials, they will spread to other States and other Insurance companies.



I have, in fact, been in contact with another Excellus “No-Dexcom-For-You!” victim recently. If that person had the “FIGHT WITH EVERY WEAPON” attitude I need, your denial might have never even happened. That person had good reasons to maintain a friendly relations with Excellus, and I respect his/her explanation. But unfortunately, when we accept denials, we encourage insurance companies to do more of them.



For those who are willing to “FIGHT WITH EVERY WEAPON”, a mode of attack which has never failed for Dexcom users who are willing to send letters with the content I specify is this:

The FDA has found Dexcom CGMS to be safe and EFFECTIVE, and there are many studies which have demonstrated large improvements in Glycemic control among Adult test subjects. If your "qualified" reviewer denies these facts, or considers my case to be unsuitable for this treatment, then I will receive a letter which shows EXACTLY the reasoning and study documentation behind such a decision. Please advise your M.D., in advance of his/her, that I may choose to use such material to ask for Board Review of their practice: If he/she feels is of the opinion that the Denial should be confirmed, it would seem that this person is practicing medicine outside the scope of their competence."

It sounds like you've submitted a lot of material about instances of Dexcom failureto warn. If so, I worry that this might not have been helpful. But even if it is helpful, it's a distraction. As a famous TV lawyer once said to his opponent, "You lost the case when you let ME frame the question."

Your letter should have framed the following question: Is the Excellus "expert" even competent, in the face of such a nonsensical decision? It threatens your life and safety -- and that person's license may need to be reviewed. Don't attempt to argue about THEIR money regarding ambulance calls and hospitalizations, or Corporate cruelty. If it doesn't create unfavorable publicity, they really DON'T CARE!

Instead, create a fight which pits this decision maker against the FDA, and against last year's NEJM study, and common sense. Don't plea with the company: Threaten the decision-making PERSON.

All of my previous "clients" have been writing a level-1 appeal. (BTW, I do this for ahem, "fun" ??? No cost to you.) So far, my clients and I have never lost an appeal. You've already sent your Appeal Letter, and perhaps given them ammunition to use against you -- But if they deny again, and if you've got the guts to be REALLY MEAN, and the desire to proceed to level 2, then I'd like to assist you with your effort.

BTW, that goes for anyone here. Just send a "friend" request.

Rick, I don’t understand what suggestions you are disagreeing with here? I am not so sure that it was a good idea to call attention to the lows that happened even with the Dexcom, but I don’t see any suggestions to Sue that would not help her case. Her 911 calls and hospitalization was before the Dexcom. I was successful because I had the ear of someone that actually listened to me as I explained that my daughter simply does not feel her lows and NEVER wakes up to them. I pointed out that it would be a very dangerous thing for them to refuse the CGM that had been alerting us to her lows so that we could make sure that she woke up each morning. Another insurance company paid for it with no appeal needed, just based on hypo unawareness.