Denied and I didn't even try!

heres the email I sent to my insurance company and their response. I am denied!

3/17/2009 10:34:10 - Dear Sarah:

Thank you for the inquiry concerning the predetermination submitted. We have carefully reviewed your policy and found that the proposed procedure is excluded under your coverage agreement. No benefits are available for continuous blood glucose monitoring system.

If you have any further questions or concerns, please contact the Customer Service Department at 1-866-536-4541 between the hours of 8:30 a.m. and 6:00 p.m. Central Standard Time or via Blue Access.

Sincerely,

Jennifer C.
Blue Cross Blue Shield of Illinois
Customer Service Center

– SARAH CONDON - 03/16/2009 12:29:53 – I was wondering if my coverage will cover the costs of a continuous blood glucose monitoring system. How much would I have to pay out of pocket?

Ah, Blue Cross Blue Shield. The same company that says I should only test my BG two times a day. But, I bet they’re more than willing cover the costs of complications . . .

Blue Cross is the same ones that said I could have a “breast augmentation” covered… but couldn’t have but a select few amount of strips a day.

Gotta love their double standards!

oh I replied to their email asking why! I told them they’d be saving so much money since complications from lows and highs cost a lot!

I asked them what I need to do to have it covered.

I demanded an answer and also mentioned that if thats how its going to be, I’ll gladly switch insurance companies next open enrollment.

ill hear back in 2 days

I have blue cross and they covered mine on the first try. Must depend what level of policy you have?

i get 250… I test 8 times a day, of course I have a small copay… like $30 for all my pump supplies, test strips, and lancets

oh they just made me mad, so now Im determined to fight them. I will get a monitor… they dont know who they are messing with

MelissaBL sent me some information to get a prior authorization override for strips - I will find it and send it to you.

I now get 400 strips a month

I have BCBS and they did end up covering my CGMS

3/18/2009 7:32:25 - Dear Sarah:

Thank you for the opportunity to assist you with your recent inquiry regarding eligibility of benefits for continuous blood glucose monitor.

We carefully considered your request but found that based on the information you provided, a continuous blood glucose monitor would not be eligible under your health care plan.

In order to receive a pre-determination of benefits, please have your physician submit a letter of medical necessity to the address below including the applicable procedure codes to be performed.

Blue Cross Blue Shield of Illinois
PO Box 805107
Chicago IL 60680-4112

If you have any further questions or concerns, please contact our customer service department at the toll-free number on the back of your Blue Cross Blue Shield identification card or via the Message Center on Blue Access.

Sincerely,

Shanda B.
Blue Cross Blue Shield of Illinois
Customer Service Center

They may be a very large, very significant company, and therefore, your comments would just be looked at and disregarded. I would change to a different insurance company, if it’s possible.

Did your doctor send in a letter to them or did you just request the info for yourself? I know with my Blue Cross(not bcbs of Illinois) they must have a note of medical necessity first before they even consider coverage, and so far they have covered everything for me. I’m not on a CGM, but my doctor wants me to go for one in the fall when I’m back home. So I won’t know about that coverage till then. Hope it works out!

Yeah, this sounds normal. Like you said, you were denied before even trying, and it only counts as a ‘try’ when your doctor submits the letter of medical necessity. There is a lot of information here on getting approval if you need it.

I think that they are almost MORE worried about dangerous lows (requiring hospitalization). That would be a high cost for them. Although I haven’t been through the CGMS process… I guess that emphasizing that this could help you prevent emergency room visits related to lows should help your case!

Ouch,
Interesting thing is it is not always the insurance company it is the policy the employer buys.

I actually have BCBS of ILL and was able to get a cgm for my pump but thru my drug coverage (Medco). Just had the Dr write the prescription and send it in. Took a month but it worked.

I tried BCBS of IIll first but was told what you already now know (no cgm, could not easily find it in the book). Not sure which cgm you are looking into but looking at your drug coverage might help.

Matthew Yarbrough

It would be covered under Durable Medical Equipment. I had BCBS of Illinois and I couldn’t even get as far as you did. I sent them stuff and faxed them stuff and they would say that they didn’t have it. I tried for months. Then my husband’s employer switched to BCBS of Minnesota. I had my Dexcom in no time. Yes, you will need a letter of medical necessity and have some of the problems they have on their list like low bloodsugar unawareness…
If I had lived closer to Illinois, I would have driven over there with all my paperwork. Thank you so much to BCBS of MN.

Sarah-

Gina Capone over at the Diabetictalkfest.com has a lot of information on her site about CGM’s. You maybe able to find help there. I would also recommend, getting all of your labwork, bg reading’s, letter of medical necessity and write a nice letter sent to your insurance company and continue to fight. Wish you much luck.

Cherise