So I’m really frustrated. I have done a lot of research recently to be able to finally get an insulin pump (which my endo is supportive of). She set me up with a CDE so I can pick out a pump that will work for me. I came to the conclusion that I really want the T:Slim G4 from Tandem which is their pump that is integrated with the Dexcom G4 CGM. I have spoken with several different insurance people, Tandem people, Dexcom people, and I got my father on board financially.
So I prepared for my appointment with my endo last week with all the research and information ready for her about which one I want, etc. All she needed to do was sign the prescription and we would be good to go (which again she was ready for and supportive of).
Dexcom/insurance requires that, for the CGM, I have EITHER:
An A1C over 7 (which I do not - and I understand that cannot be fudged)
OR
I have had severe hypoglycemia
Now I have had hypoglycemic episodes in the past. The lowest number I have had was 43 and it was very scary. I also have had a lot of numbers in the 50’s recently which my doctor has logged/charted. I have never been hospitalized or been unconscious due to a hypo but they are scary and I am trying to decrease their frequency (part of why I want a pump).
So, my doctor would have to check the box of “yes, her A1C is over 7”, OR, “yes, she has had severe hypoglycemia”. My doctor refused to check the box that I have had severe hypos! She has seen my numbers in the 40’s and 50’s recently and said that it would be untrue if she checked the severe hypo box. I understand she has integrity and is unwilling to “lie”, but to me, this would not be a lie. Do I need to be passed out on the floor in order for it to be considered severe hypoglycemia? I have hypo unawareness and I have experienced 40’s and 50’s which I figured would be a sign that this CGM would really help me.
I’m not sure what experiences people have had, but if I were to guess, not everyone that gets a CGM is hospitalized because of lows… meaning their doctor has no issue checking off the box indicating that lows are indeed a problem. The A1C is an objective number, I get that. But checking off “has had severe hypoglycemia” is much more subjective and I really feel she should be checking off that box for me. I’ve done a lot of work to get to this point with insurance and everything and it seems crazy that she refuses to do this for me. I obviously will not be creating hypo’s for myself to get this CGM but I’m just frustrated with this whole thing.
Do I consider changing doctors if she is unwilling to do this? I really would love the T:Slim G4 and I feel she is not going to budge on this. I am super frustrated because of all the work I have put in to get myself and everyone to this point. Thanks for your help guys!
That is frustrating. It may simply be that her definition of “severe hypoglycemia” is different from what your definition is, or what Dexcom’s definition is, or what your insurance is. As you say, it is subjective.
Can you call a Dexcom and/or an insurance rep and ask for a more objective definition of “severe” hypoglycemia? If everyone is on the same page, and Dexcom/Insurance agree that multiple readings in the 40s-50s are “severe” despite not going to the hospital because of it she may be willing to check the box as she won’t feel that she is lying.
The requirement that for the CGM, you have EITHER:
An A1C over 7 (which I do not - and I understand that cannot be fudged)
OR
I have had severe hypoglycemia
is not something I think your doctor can “fudge”. I would never ask my doctor to check a box that was not true. Severe hypo is an interesting ‘rule’ but since you have not had them then your doc is doing the right thing imho. Severe for you and severe for me are likely not the same thing. Do you have a dx on your chart for the hypounaware issue? That would do it. Good luck.
Does she have T1 and does SHE know what 40s or 50s feel like? If not, maybe she’d like to shoot up some insulin just to try it? Cause those numbers certainly feel severe to ME.
I’d say she’s had them. Anything in the 50 range and I start having flash-bulb spots and cone vision in addition to the usual shakes etc. That’s not severe in your opinion? My endo checked the box for me on the basis of those kinds of lows (or less) and there wasn’t any question of her “fudging” anything. Unless the only qualification for “severe” is waking up in the ER, I think the OP’s endo is nuts.
How do yuou (and yur Endo) know that you don’t have severe hypos at night? That is one of the biggest benefits of CGM - knowing what is going on during the night - 1) you get an alert so you can stop the hypo (and hyper) in its tracks, and finding out when they occur. If they occur regularly at certain times, you can tailor your insulin rates to fix the issue.
Whoa Whoa Whoa! I am a hypounaware T1, and know ALL about it. I said “Severe for you and severe for me are likely not the same thing. Do you have a dx on your chart for the hypounaware issue? That would do it. Good luck.”
Suggesting anyone ‘shoot up some insulin to try it’ is just silly, and not much help. There is a REAL dx code for those of us who walk with hypounawareness on our backs. THAT will get a CGM faster than a doctor who is asked to “fudge”, and expected to suffer a hypo of any kind.
It doesn’t matter what you say. What matters is what the requirements say. And the OP said she has had lows that were very scary. Not to start a new argument but Severe is the questionable definition. Most of the stuff I read suggests severe means the person can’t treat the hypo without assistance.
There are solid, honest, respectable ways to pursue the desired device. I suggested one from experience. Geez, I must have picked the wrong day to quit hypoing
When I applied for a CGM I filled out the paperwork, not my doctor, all she did was sign it and turn it in for me. I’m not sure if she had to fill out anything on her own, but I can tell you that although I had a few hypo’s while under her care, I don’t think any of them were below 40. I did tell her of hypo’s I’d had not long before starting to see her (at least one of which I was unconscious) but had no hard proof to back it up.
On the other hand, my A1c was 7.8 at the time I applied for a Dexcom CGM and Animas Vibe pump. So that’s probably what got me the OK.
Believe me, I am not suggesting that you do this and I personally would never do it. But here is a story of a man in Israel who injected extra insulin in order to go to the ER and get documented visits for low BG.
Find a doctor who is more supportative of CGM’s. It only takes one low to be an issue if things don’t go right. My feeling is anybody on insulin should have the option of a CGM.
Hi - I’ve had T1 for 50+ years and there are a couple of ways that you can get your doctor to write an Rx for the pump and CGM.
The Dexcom CGM delivers an alarm at a BG level of 55 automatically. I set an alarm at 80 also, because below 60 and I am not able to get juice on my own dependably.
When a type 1 diabetic is alone (no one else in the home) and gets that low, it is a horrible, horrible experience that can take hours or even a full day to recover from, even if you can crawl to the refrigerator or can find glucose gel or tablets before you loose consciousness.
Ask your doctor for a brief written statement saying that they will take responsibility if you go down to 32, feeling just fine (has happened to me) and it becomes too late to call 911. Being that low feels like you’re on drugs (I’m being subtle here).
At the Joslin Clinic, they always say “you know your diabetes better than anyone else.” If your only doctor refuses to prescribe you the tools you need to stay alive, they need to put it in writing. You might need a family member to write your doctor a letter as well. Best wishes and don’t give up.
Here in Switzerland the requirements are similar for CGM funding. Thank God my doctor is awesome and counted the few times i woke up at night with BGs in the 40s and NOT KNOWING WHAT TO DO (like the one time where i went to the kitchen to grab pesto believing that would help my low and only realizing it was the wrong jar when i had already returned to my room) as severy hypoglycemia. Unless that doctor has experienced the lows you are going through and the fear that comes with it, he has no right to refuse that tool to you.
put it in writing or switch endo if possible.
good luck!
A couple of thoughts. Check with your insurance to see what they require to qualify for a CGM. Just because its on the Dexcom paperwork doesn’t mean that your insurance require you fall into one of those two categories. My insurance just required that I be a type 1 for CGM coverage. You can also check whether your insurance covers CGM under prescription benefits. If so then you only need a prescription and no statement of medical necessity. Second thought is Tslim G4 is only compatible with the Dexcom G4, not the G5. So you won’t be able to get the CGM readings on your phone with the G4, just on the pump and on the receiver. I ended up returning my tslim G4 for the regular tslim so that I could continue to use the Dexcom G5. Having my readings available on my phone is more practical than on the pump since the pump isn’t always readily accessible.
Most insurance plans policies will consider hypoglycemic unawareness as grounds for CGM. Severe hypo most generally is recognized as being unable to provide treatment, requiring a trip to the ER. Most people I know who get authorized for CGMs at my work (I work for a insurance plan) get it for the hypoglycemic unawareness, or large variations in their blood glucose levels. Not so much the documented severe hypoglycemia. I think that is a Dexcom thing, and insurance plans review based on their criteria, not what is just on the Dexcom form. Agreed if a CGM is what you want, then a doctor who is more CGM friendly may be an option. Discussing with your doctor how you feel during your hypo’s too may also help them see it as being potentially severe. You can call your health insurance plan and request their medical policy for CGM to see what they specifically require for coverage. Hope you get it worked out.
