Denied Dexcom G5 By My Medical Group

Hi All,
Went to my doctor last week and she wants me on the Dexcom G5, my insurance just changed to Blue Cross HMO and the medical group that is assigned for my area just sent a letter saying it was not a medical necessity I am not sure what to do. I have been a type 1 for 36 years and I have no clue most of the time when my blood sugar drops very low. I can be walking around perfectly fine with it as low as 32. How is this not a medical necessity. I worry when I drive all the time because I just can’t tell. I am going to fight there decision but I am not sure how to approach it. I was wondering if anyone else has had this problem.

Wait, I am confused. Your BCBS HMO doctor wants you on G5 but the higher up beancounters at the BCBS HMO refused it on grounds that it is not medically necessary? Your doctor should write the letter of medical necessity, not the beancounters. I presume there is an appeal process. Do you know what it is?

I recommend calling Dexcom and getting them going on this. While the technology is a huge game changer, it’s a sales thing and they are set up to blow through the BS that you encounter trying to be civil with insurance companies. The D-Gear dealers are set up to do this and I’d much rather have them call every other day for me than to call every other day myself. They can act as an intermediary and deal with the back and forth of getting a (stupid) letter from your doctor to the insurer and keeping the pressure on the phone answering people at the insurance company while the people who approve things at the insurance company contemplate whatever they contemplate. Waiting is frustrating but the gear dealers are the people who will work for you.


Yeah it says I can file a complaint on the letter and there is a phone number to do so.

I would recommend giving the complaint number to Dexcom although I suspect that they already have it. They probably have dealt with the same insurance company. Dex is selling you a gizmo that costs thousands of dollars up front and offers them the chance to create a lifetime fan, or at least one who will likely like it until the cure rolls around. Insurers seem to have barriers in place to getting quick answers about things like pumps and CGMs that the companies making them will overcome for you, one call and little frustration vs. making many calls and pounding your head into it. Just calling and entering your 12 digit plan number, policy number or group number drives me batty. I’d pay extra to have someone else do it but here, the vendors can do it for nothing, or for themselves and I’d suggest that!

A decade or two back when I had somehow accumulated 2 speeding tickets and was about to be cited for a third, I hired a lawyer. At some point I asked why I should bother. After all, what could a lawyer do that I could not do. The response was that the lawyer knows how to make the ADA’s life more tedious and annoying than I do, hence more open to compromise to avoid it.

Perhaps it is somewhat the same thing with getting the device company, Dexcom, to advocate on your behalf. Sure, maybe it won’t work, but how does it make sense to not at least give them a shot at it? Especially since you seem to have your doctor behind you on this one and history of hypo’s to support your necessity claim. No?

@melsk – I highly endorse @acidrock23’s suggested tactic. The medical argument is squarely in your favor. You have hypoglycemia unawareness and that threatens your basic safety. A well-crafted letter from your physician, helped with all the right words supplied by Dexcom, will put your insurance company in the uncomfortable position of possible complicity in any future accident or hypo-incident that you may endure.

The right combination of words exists to unlock your insurer’s reluctance and Dexcom has that combination. Use them now! Persist with your appeal until you wear them down. You are not the first to appeal and win.

Make sure the doctor’s letter includes the exact words “letter of medical necessity”.

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My prior medical insurance initially denied Dexcom for me. They required two lows below 50 documented on my meter in the course of a month. When I was able to later provide that evidence, they approved the Dexcom. Perhaps your insurance has a similar requirement. Did the denial letter they sent include any information as to what constitutes medical necessity?

Dexcom helped me but I was asked to keep a written record of blood sugars, instead I printed out my meter report which showed a low of 23 (I’m hypo-unaware) they quickly gave the OK and sent me one. If your meter has a computer program and you can print reports that show any lows it can help the process along.

i will call Dexcom, i won’t have a cgm, today if it was not for me calling them,.

& i will file a complaint, like acidrock23 says to do,.

You got lots of great advice from Acidrock abnd Terry. What I don’t understand is that healthplans will “gladly” pay for the $17,000 or so that a visit to the emergency dept costs (without admission). Dexcom, together with your LD’s efforts should work - especially if they cover it elsewhere. I have Kaiser and they cover it in California, but not in the Pacific NW. I still didn’t get full coverage, but I pay what Kaiser in CA pays - which saves me about 50%.

Seems more often than not, some high school grad is making medical decisions (the just say no claims dept employees)

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Thank you everyone tomorrow will be a busy day and hopefully in the not to distant future I will be able to get the Dexcom. All of your info is very helpful.

Err… Not exactly a tough barrier to jump over. If they were to offer me funding for a Dexcom 5 under those conditions, I would make sure I had 2 readings below 50 by the next day…

LOL, my advice is not to file a complaint, it’s to outsource your complaining to professionals at Dexcom!!

If you call and complain, your complaint will likely be escalated to a pile of complaints and somone else will follow up to respond to your complaint, maybe by simply sending out some sort of letter, perhaps similar to one(s) you may have already received, saying “no”, or maybe even just acknowledging your complaint. That will take a week or two where nothing else will happen.

The best outcome is that they look at your case however, if their ducks are in a row (and they tend to be…), they can have a “nurse examiner” check your case and make a medical determination that a doctor (I would suspect they have a stable of them…) indicates no need for what you are looking for.

By having Dexcom handle the transactions, they will work to overcome these hurdles as they have for their other customers, make the calls, send the letter, play their own cards to trump those held by the insurance company.

[quote=“jjm335, post:14, topic:50916”]
Not exactly a tough barrier to jump over. [/quote]

Which is why I was able to show them what they needed. :slightly_smiling:

Yes, I thought “somewhat exactly” (??? :confused: ) the same thing when I read that. I immediately flashed on how time after time after time after time after time after ti… well, you get where I’m going … I have been strongly pushed in the other direction by a doctor, nurse, et cetera. Better to risk long term side effects in the future than experience low BG now.

Can we legislate that insurance companies must follow the hippocratic “first do no harm” oath thingee? :wink:

Ah, if only something like that were both possible and would actually work. :disappointed:

Does that work universally with doctors, or does it depend on who is writing the check?

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oh, sorry my bad, but, outsource, it to, Dexcom, is good, they, took, care of the stuff, i had, going on, with my,.

I’ve been on Medtronic CGM for about 8 years now. The CGM company sent a Letter of Medical Necessity to my endocrinologist to fill out, with all the proper verbiage and he faxed it to the Insurance company. It was approved and I’ve changed insulin pumps and CGMs to a newer model 3 times all of which were approved by the same process. Some specialists, such as endocrinologists or internal medicine, are more familiar with the verbal hoops required in the letter. But as everyone suggested Dexcom has dealt with reluctant insurance companies since CGM has come out, so have them help you. Best of Luck!!

Basically insurance companies always refuse first, hoping we’ll just give up and go away. Be persistent and you’ll be CGM’ing in no time.