Denied for Dex--A Rant

Diabetes Technology Glucose Monitoring
1

Hey guys,
I had finally made the decision a few weeks ago to go ahead and order my own Dexcom system. I had a couple lows in the 30's and 40's before I could really feel myself getting low and that scared me. I wanted to have a heads up. After 13 years of this, I felt I might finally have unawareness of lows.

Well, Dex had to get a third-party approval to make sure my insurance would deem it medically necessary and they denied me. The explanation doesn't even make sense (misspellings and grammatical errors are theirs):

"A lifetime continuous glucose monitoring devise is not considered medically necessary based on the enclosed records and standards of medical care. There is a glycemic log over 1 month, but short-term CGMS has not been used in the patient to improve her control. Hypoglycemic episodes are uncommon, and there is not documentation of frequent episodes of hypoglycemia requiring acute hospital management. There is no established evidence of nocturnal hypoglycemia or hypoglycemia unawareness. She mainly exhibits hyperglycemia and further improvement could be achieved in adjusting the diet and insulin regimen. There is not documentation of type 1 diabetes. She does not have recurrent episodes of ketoacidosis, hospitalizations for uncontrolled glucose levels, and frequent nocturnal hypoglycemia."

Is it just me or is this completely baloney??
1. "but short-term CGMS has not been used in the patient to improve her control." Yeah, duh, I'm trying to GET a CGM so that I CAN improve my control. Hello, is there anything in that cranium?
2. I'm still adjusting to life on a pump, so my basel rates do need to be adjusted and that is why I've been running in the 200's--no, I don't have a lot of hypoglycemic episodes now...I'm trying to PREVENT them!
3. "there is not documentation of frequent episodes of hypoglycemia requiring acute hospital management." You want me to be sick enough to require hospitalization before you will approve me for a small machine that will help prevent hypoglycemia that requires hospitalization??
4. "further improvement could be achieved in adjusting the diet and insulin regimen." I have been working my TAIL off to improve my diet. It's better than most people's, I can tell you that!
5. I could go on, but I'll make this the last point since it makes me incredibly angry: "There is not documentation of type 1 diabetes." Where did this idiot go to medical school??? They need to revoke his/her license immediately! What have I been suffering through for the last 13 years?? I'm on insulin...that's approved by insurance. They pay for it. I just had to prove my type 1 diabetes to get approved for my Omnipod. But there's no proof of type 1 diabetes now? Really.

I'm definitely going to appeal this decision. I'm just waiting to hear back from my Dex rep and see if he can provide any advice or help. Has anyone else been here? Did you get this same stupid reasoning that I did?
I guess I've been fairly lucky so far with not running into too many idiots like this when dealing with insurance. My luck seems to be changing now....

2

Had to go through the process 3 times before I was approved - and I had a similar reaction when I was rejected by the insurance company (very similar reasoning was provided). I have several friends who had similar experiences as well (at least 1, if not more, rejections). Someone explained to me that the "answers" needed are actually in the 3rd party response. At the time the exercise I was doing was starting to cause more frequent night time lows - and I was able to document that over the course of a month or two. Hope that helps a bit. Also want to make sure your doctor has provided any relevant supporting material that they have and letters of recommendation that the insurance folks may need.

3

I too suffered from nocturnal hypoglycemia. All of my paperwork was submitted by my doctor. Do you have an endocrinologist that will work with you to resubmit your justifications?

4

KCCO,

Wow, you are lucky indeed if you have not run into idiots like this in the insurance world! One of the worst things about having Diabetes (besides that it will kill you if you turn your back on it) is dealing with insurance companies. I remember long ago that in MA, insurance companies would not even cover test strips!

Anyway, CGM is still pretty new and the insurance companies are still in their default behavior of 'deny everything'. Always remember insurance companines care about one thing only, and that is how much money they bring in, and NOT about anyone's health, and especially not preventive health items. Logic will not be present in their arguments.
Stick with it and try to figure out what your particular company wants or needs to see to 'justify' it.

One of the items they mention works very well - hospitalization from a low. I speak from personal experience, I lost symptoms of lows a few years ago, and started having blackouts where I would be doing something, then later be in a different room or place, often with a bunch of sugar packets or juice and my wife looking at me. That was scary enough, but the real fun came when I woke up on a stretcher in front of my house one night. I remember looking up at the stars and thinking 'wow, something really bad just happened...' Had a very bad low at night which then turned into a seizure.

A few years after that I was diagnosed with Systemic Lupus, and was dealing with that and the meds that made diabetes control very difficult. Had another seizure, hospitalization again, this time had to stay longer because of the Lupus angle. I knew what had happened and wanted to get out of there, but had to stay for a few days for extra tests and that is how I ushered in the new year 2011.

After the first seizure I got a CGM (they were new then, I was part of a study, you could not even buy it then) and it saved me repeatedly, and taught me a lot about insulin, eating, and timing.

After the study was finished and CGM units started getting FDA approved, I had to go through the insurance maze. The key was the hospitalization for getting the unit covered. However, over the years I have had to change insurance companies a few times, and have actually quit a job because the coverage was so bad I could not afford to pay for all the extra diabetec care supplies on my own and stay healthy enough to work. Getting insurance to cover the sensors is still a major pain in the butt even if you get the unit approved.

Anyway, sorry for the rant, keep at it, and it could be worse - I would not wany anyone to go through a seizure, and unfortunately that is one way to get approved quickly through most health insurance companies.

Another way is to get another health insurance if at all possible - some are better than others for CGM and diabetes care. Some actually do try to help you stay healthy. Others, well.....

-CG

5

I know when I applied for my Dex my endo submitted my c-peptide results that she took to qualify me for the pump (to prove I was type 1) of course I had been diabetic over 15 years at that point but included it to appease the insurance.

We also included documentation of several significant lows with notes that I had little to no warning of the ie hypoglycemic unawareness.

I do not recall is the lows were overnight or not. Thank heavens, I have not been hospitalized due to lows. Had to call an ambulance once the summer after my freshman year of college, but was treated and released.

Not sure if my story helps. keep at it though the dex is a huge help to me. You might also want to find out if you can do a test run with the Dex and show that is makes a difference. I got to borrow one, only got one sensor, but I actually restarted it and got nearly two weeks out of it. Maybe that would help?

6

Hello KCCO: Insurance companies are such a pain. First, get the guidelines used in the determination. Each insurance company policy has these guidelines that the reviewer must use in order to approve or deny your application for the CGM (or for anything else for that matter). To get those, call the insurance company directly. The guidelines, for instance, for United Healthcare to approve the CGM are that the person's A1C level is above 7 and/or the person is unable to achieve optimal glucose control as defined by the American Diabetes Association. Then, locate on the ADA website their definition of optimal control, which will help you greatly. The ADA guidelines include both an A1C of 7 or below AND pre and post prandial numbers listed in the ADA guidelines as a determination of "optimal control".. Most insurance companies, and unfortunately many doctors don't really read the guidelines and think if your A1C is below 7 you have good control. But, that's not the guideline and that's not correct. If your pre and post prandials are not in line with the suggested ranges, then you are not in good control. Then, look to see what your standard deviations are for each time of day. If you don't have a program that gives you that, but do have an IPod, get online and download the Wavesense Diabetes management program. Then, put in all your data that you gave to the company, making sure to put in the correct dates and times. This is tedious, but it is important. It will figure your standard deviation for you. The higher the standard deviation, the lower your control. Use that argument in your appeal.

Did your doctor assist in completing your request for the CGM? Mine did, and she was totally incompetent when it came to getting it for me. She did not mention hypoglycemia unawareness, which I've had for years. You need to make sure you emphasize that you can get very low before you notice hypoglycemia and that getting that low affects your functioning before you notice the low. Just because you haven't been hospitalized doesn't mean you don't have hypoglycemic unawareness. See what I mean? The human brain doesn't work well on blood sugars of 40, even if you aren't unconscious, and if you get that low before you notice you are low, you're experiencing hypoglycemic unawareness.

So, your first task is to get the insurance company guidelines for coverage. I don't know your state, but in California, insurance companies MUST provide those guidelines to any policyholder who asks for them. When I went through my appeal, UnitedHealthcare was very uncooperative until I looked up the code section in state law and called them back and read it to them. I then got the guidelines in the mail a week later.

You may have to do some of your own legal research. I did, but it is so easy now with the internet.

Don't give up. If you have any trouble finding the ADA guidelines, let me know and I'll send you the link. Good luck.

7

Thanks for all the advice, everyone.

My current CDE and doc are amazing. I switched to them because they were extremely familiar with pumps & cgms, processing the paperwork and all that. My doc will give me any paperwork I ask for and gladly. I know they submitted my c-peptide results when I got my Omnipod just about a month and a half ago now, so I would have thought they would have provided the same thing for Dex. Maybe it was not requested by the insurance at the time...I'm not sure. I've left them a message though, so hopefully we can get it resolved quickly.

My a1c was about 6.4 at my last visit, but I feel sure it will be higher when I go in next week. BUT we all know the a1c is not the be-all and end-all indication of optimal control. And no where have I read that a Dex should only be used for predicting lows--being high is just as dangerous, only over a longer period of time.
Pre- and post-prandial numbers are where I fail to meet the guideline for optimal control. Thanks AlexJ, I will definitely look into their guidelines.

I will treat this like a college research paper, get my facts and numbers, show them that I'm not just some random person who doesn't actually care about my health, but that I'm proactive and want to prevent future complications. BAM!

8

You sound much more hopeful today. Good for you. You're going to get your CGM. I'm sure of it.

9

Hey KCCO, you've gotten great advice here. I didn't have any problems getting approval for my Dexcom and was actually surprised at how fast my insurance approved it.

Did you fill out a "Patient Information Form" for the Dexcom rep? If not, it's on their website. There's a section on this form for you to put "anything else you would like us to know to help support your need for a Dexcom". This is where you can use your standard deviation and pre and post prandial numbers as well as hypo unawareness. This form, along with the doctors statement, is what Dexcom uses to make your case to your insurance company.

I took full advantage of that section and wrote at length about my hypo-unawareness, my need to be healthy enough to keep working to keep my insurance benefits, the bg roller coastering, my problem with pre menopausal hormones and anything else I could think of to justify. I've never been hospitalized with lows but have needed assistance from my husband before. I also tried to describe how a low affects me physically and mentally so I try very hard to prevent them so I don't end up in the hospital.

Maybe they just approved mine to shut me up! :) Good luck with your appeal!

10

Lol....nice.
Thank you!

11

It seems like getting CGM requires saying/writing the correct thing. My endo knew exactly what to write (and I had two ER visits as ammo - both my fault but insurance didn't ask that!) and good insurance. My CDE reviewed and submitted all the paperwork. She and the endo did something right because I was approved in 2 hours! She said it was the fastest approval she had ever seen.

Good luck getting the approvals. I have both a pump and CGM. If I had to chose between, I would probably choose CGM.

12

Sometimes it’s just a matter of pulling together the documentation your insurance needs. The info may be there in your chart just wasn’t submitted to Dexcom.

The short term cgms your insurance is looking for is the professional cgms that dr’s use where they hook patients up for 3 days. Some insurances will require this to be done before they’ll sign off on a personal cgms. I had to do this. It’s actually helpful as it can really show things the insurance is looking for. My dr had arranged for me to have a Dexcom trial rather than an I-Pro study as I had developed an allergy to Minimed’s sensor previously. He submitted the cgms data along with chart notes and logs and I got approved right away for the Dexcom.

13

KCCO, your writing sure brings back some awful memories.
I appealed three separate times. Each appeal was detailed, different, and well presented. Needless to say, I put lots of effort into my original request and the three appeals.
In all four requests for a CGM their response was identical: "Your request is denied because this device is considered experimental".
I received Ins. Co. approval over two years ago due to the fact that I finally realized I'd be far better off spending my energies in search of an Ins. Co. that has covered this particular piece of hardware previously. I found one and changed Ins. immediately.
My frequent hypo. events stopped beginning with day one using the CGM. I am very satisfied with it but am looking forward to better accuracy in the future.

14

To update this:

I did a one week trial of a Dex sensor and loved it. I really missed it when I had to hand it back to my CDE. My doc and the CDE have turned in all the requested paperwork for an appeal and I'm in touch with a rep from Dexcom every couple of weeks to see how things are progressing.

So far, nothing. It's been over a month and I'm worried they're just going to deny me again. I really wanted to get it this year since my deductible is already paid. Here's hoping....