Denied CGM Coverage

GRRR!!! I’m so frustrated… I was approved for the MM Revel pump with built in CGM without any problems, but my insurance BCBS denied coverage for the transmitter and sensors. I got the call from my endo saying this along with a letter of the appeal process from BCBS and I can’t figure out if it’s just the lack of information, they didn’t have any logs sent to them, or if it’s just someone just having a bad day and decided to pass it on to me. Anyone have any experience in the appeal process? They were fine with paying for my Dexcom sensors, the unit itself was paid for under a different policy, but I can’t get them to pay for the MM sensors. I’m in the middle of midterms at school and I’m trying not to freak out, but it’s stressing me out and I can’t deal with a lot of stress in my life right now.

I’m calling BCBS tomorrow to see what they suggest… it’s gonna be a fun time! LOL


I will be dealing with them shortly on the “test strip” issue? I am dealing w/ BCBS of IL/TX/OK/NM so it may be different but I have the sense they are making me prove up my need for the stuff? I can think of all sorts of ways to do this…“c’mon, let’s go for a ride in my car…no, I’m not gonna test my BG, you only are giving me 6/day!”.

I wouldn’t call them and ask them what they suggest, I would call them and tell them what they are going to do. Take the high ground. I have until April, and just got my “old” order of test strips today but I’m totally going to feud with them if they mess with me. And, if they punt and give me what my doctor recommends/ what I want, I will still feel very badly for the people who don’t go after them.

I’ve had problems with United Health Care not wanting to pay for MM sensors. I didn’t NEED the senors so I didn’t fight it, but they were only going to cover about 5% of them, as opposed to the 30% that they cover for the rest of the pump supplies.

See I haven’t had any issues with my test strips. I get 300 a month still even with CGM coverage, or at least when I use to have CGM coverage! I have even filled my scripts twice this year without any issues… but I’ll be looking for the letter any day now in the mail! LOL

Yeah, I’m gonna have to tell them this is what they are going to do… they said I didn’t have enough lows to warrant the CGM, but my argument is that I can prevent most of my lows because of the CGM. I just can’t make them understand that!

Anna, mine pays 80% until I reach 2k then they pay 100% of all DME supplies which include sensors. I really need them as I don’t know when I’m low anymore and it just helps as I live by myself to have that added sense of security.

If you have hypo-unawareness then can you get your doctor to write a letter to the insurance stating that you have to have it? Most insurances are a little more willing to pay for something if it keeps you out of the hospital…or from dying.

Hi Elizabeth, I have Anthem BCBS and they covered my CGM supplies for my MiniMed Paradigm at 100%. I am enrolled in the Gold plan-most expensive. I did try to appeal a totally different decision they made in another area and it didn’t go well. I find BCBS very difficult to work with most of the time. When i have a question, i call 3 times and usually get 2 or 3 different answers. I usually choose the answer that was given most often. You can call them yourself and get to the bottom of this. Ask them direct questions and don’t hang up until you talk to someone in charge-a supervisor- Start the appeal process once you get the info from the horses mouth. Who knows, the next person you talk to may say you’re covered! Then call a 3rd time and see what answer you get :slight_smile:

Several insurance companies use this standard: patient must have multiple lows under 50 before they will approve. If your doctor documents that you are hypoglycemic unaware, that may help also. I would appeal it, because you have nothing to lose by trying. Strange that they will pay for your Dex sensors though. Dex is a great system, would you consider using it? I actually prefer it to the MM cgms, although I understand you want the integration.

I recently had a go round with my employer and BCBS Michigan. BC normally would cover but the plan that my employer selected had excluded cgm as a covered benefit.Several of us called and talked with the HR folks at work and inside a month the policy was changed so that CGM is a covered benefit where medically necessary. I submitted Dr’s letter, medical history, 60 day logs (need to have a couple under 50 per month) and after a slight delay due to fax machines both my wife and I were approved as was a friends daughter. A side note - stay with theDexcom - its more accurate, lasts longer, is more comfy and easier to read. I have tried bothand the Dexcom is hands down. I wanted the integrated pump,b ut after trying it I am happy with the pump and meter seperate.

Hopefully its just missing documentation, so start with a phone call and try to find out what the issues are. I pulled alot of documentation together and forwarded to our HR group and I think it was helpful in changing the policy. I know that BCBS lost a court casein Michigan over CGM and was ordered to pay in a specific case. Hang in there and good luck!

Ihad a much better experience with them. When theyapproved my CGM, they asked is there anything else you need? Are you all set with pump supplies? Do you get enough strips? If you need more this is what you need to do …

Kelly , in the Canadian Group posted a discussion on " Form letter to ask employer for insulin pump coverage " , October 2010 …I suppose same can be said for CGMS
PS I don’t know how to post the discussion here ; maybe someone can help …and hope it is useful . I am sure Kelly would not mind me mentioning her discussion .