Health Insurance stopped covering my CGMS

I received a call today informing me that my HMO (Harvard Pilgrim Health Care) has decided to discontinue coverage of the CGMS. I am so sad. My A1c at the start of my CGMS use was 7.4%. Within 90 days of CGMS use, I dropped to a 6.7%. I am so sad that they will not cover it anymore as I cannot afford to be on it without their assistance. At $30 per sensor I will be paying just under $90 per week to continue using this. I cannot keep the sensor on the 6-7 days that some users are able to due to sensitive skin irritation that I encounter if I push use beyond the 3-day mark. I will have to give this wonderful device up once they discontinue coverage…date TBA. If you have Harvard Pilgrim, please help me to fight this! Call and voice your opinion 1-888-333-4742. They need to understand that they will ultimately pay more money covering our medical bills due to diabetes-related complications (that this wonderful device can surely help to prevent) than they will for paying for this device upfront. I feel defeated; I was so very happy with my health plan and everything Harvard Pilgrim was doing to help me improve my health. Now, I feel that they have given up the fight.

Is there an appeal process that you can go through? You need a very good MD letter and documentation about the CGM and start the appeal process. It also sounds like you could use a lawyer, or maybe on your appeal letter you need to write that you will be seeking legal counsel.

Well, the HMO is not targeting me so I am not sure if my situation fits the criteria for needing a lawyer, etc. They have, for what reason I do not know, decided to stop covering the CGMS for all insured. I cannot fathom why, other than cost, and we all know the cost of using the CGMS is nothing compared to the cost that the CGMS saves down the road with expenses related to complications, etc. I am devastated by this termination of coverage. I have been using this incredible device for 4 months now and cannot imagine not having it. In my 20 years as a diabetic, I have NEVER gotten my A1c under 7% until I used this CGMS. My very first A1c reading on the CGMS was proof enough to me that this device does it’s job…and does it well (6.7% from 7.4% just 4 months prior). I am at a loss.

Call your insurance and file an appeal, it cannot hurt.

You are right. I will pursue this. Thank you!

Depending on where you live, I am sure there are laws against an HMO refusing to cover services that it once offered. I know that in California, if an insurance company used to cover a specific medication they have to continue to cover that medication for you, but not for all patients subscribed that med in the future.

At the very least, I would say an appeal is necessary.

I think in my area it is completely legal. Their reasoning is based on the fact that they said that they have found that there is not enough scientific evidence/data to support the effectiveness of this device. I did get very lucky, however, because they extended my coverage through 3/31/09. They did this for anyone already covered for this system. That makes me happy, but I still want to fight for this…for those who were not yet covered and for those of us who will lose coverage in MAR 09. I have attached the letter that my health insurance co. sent me. I had to speak to a few ppl before I found one that would put something in writing.
8650-HPHCletter.jpg (1.06 MB)

Great news! I have heard that a doctor in Atlanta, GA (David Body) has done some research on the effectiveness of the CGMS pump that has helped convince Harvard Pilgrim Healthcare to cover this system again! I have not tracked down any proof of this online yet, but the news is so promising!!!

Woohoo, great news!!!

I should start wearing the sensors again, I gave up on vacation and have not resumed.


Correction, it is Dr. Bruce Bode.

Hi if you find any info on this research can you please post it? I am currently fighting my plan to cover my sensors. Thanks!