How does Medicare coverage of CGM affect you?


#1

Hey friends,

Diabetes Hands Foundation (parent organization to TuDiabetes) has connected with a group called HCM Strategists, which does public policy advocacy around health and education. They’re organizing advocacy for Medicare coverage of CGMs, and have asked me to identify some community members who are interested in, and passionate about, this issue. We’re particularly looking for folks who are willing to share their personal stories about how Medicare coverage of CGM affects them.

If you’re interested in sharing your story, or taking a more active role on this issue in some other way, please let me know in the thread below and I’ll connect you with the fine folks at HCM! They are seeking people of ALL ages for this effort.


Medicare appeal for CGM payment..HELP!
#2

I have an MVP health insurance plan. It is affiliated with Medicare, so MVP must follow Medicare rules. Dexcom tried to get their CGM approved for me. It was denied. My endo then presented a letter of medical necessity to MVP, mentioning my hypo unawareness. I was turned down again. Here is the explanation from MVP for the denial:

“Per the MVP Policy Continuous Glucose Monitoring long-term continuous glucose monitoring systems beyond 72 hours (A9276, A9277, A2978) are not covered for Medicare products. Therefore the request is denied.”

The denial is not very well worded. I think they are objecting to a device that is used in the skin for more than 3 days. An infusion set for a pump is usually recommended for 2 days, but many of us use them for 3 days. So MVP/Medicare approves pumps and infusion sets. A CGM sensor is recommended for 7 days, and many of us use them for 14 days, or longer. That is much longer than the 3 days approved, so MVP/Medicare denies coverage of a CGM.

I wonder why having a sensor in my skin for more than 3 days is considered inappropriate by Medicare. Does anyone know?


Medicare denial of CGM devices
#3

@Richard157, may I connect with with my contact at HCM? She’s a very nice woman, looking for stories like yours to share with policy-makers.


#4

Sure, Emily. make the connection whenever you are ready.


#5

Sign me up twice. I woudl love to explain why it is need and how it can be used. One of my members Rep Susan Brooks is on the committee hearing our case right now.

rick


#6

Emily-Although I am involved in advocacy for CGM Coverage by Medicare, I am not yet Medicare age. April, 2017 is when I transition to Medicare. So not sure if I should be part of this or not.


#7

Almost a ditto for me as well. I have until April 2019, but I am hugely concerned for our current insulin dependent seniors who are being denied coverage.


#8

I’m glad you asked that, @Laddie! Actually, they want people of all different ages for this effort. As you know, the issue extends beyond folks who are on Medicare because other insurers follow Medicare’s lead, AND access to artificial pancreas technology - once it’s on the market - will be tied to the Medicare-CGM issue. Because of that, we think of this as an issue that’s really important to people of all ages who have diabetes!

May I connect you with HCM, @Laddie?


#9

Hi Emily,

I’m a long term Type 1, having been diagnosed as such in 1971.

My endo prescribed a CGM for me when I was 63. I had several serious hypoglycemic incidents prior to that, that resulted in 1 hospital admission and several trips to the ER. In addition, I broke my ankle, when I lost consciousness, while preparing breakfast. The most terrifying experience I had was when I discovered myself weaving across a highway. I had checked my blood sugar 60 minutes earlier and at that time it was 120.

In December, 2011, I turned 65. Medicare Part B, along with a supplemental plan from GHI provide my health insurance. They cover my test strips (10X a day) and pump supplies. I have been self funding my Dexcom CGM and sensors.

I am a very active person. I either bike (10.5 miles), or jog (3 miles), every day. In the winter I ski. I also drive long distances. None of this would be possible without my CGM.

I am fearful of what I’ve been hearing in the presidential debates. Most of the Republican candidates want to cut Medicare & Social Security Entitlements (I hate that word. I paid into Social Security and Medicare for 47 years and now I’m told that it’s an Entitlement).

With next year’s increase in Part B Premiums, I am unsure of how long I will be able to continue to self fund my CGM needs.

I would be glad to share my story.


#10

Emily, you can connect me with them. Thx.


#11

“An entitlement is a government program
guaranteeing access to some benefit by members of a specific group and
based on established rights or by legislation. The term may also reflect
a pejorative connotation, as in a “sense of entitlement”.”

I’m fine with the non-perjorative connotation of “entitlement”. I too want guaranteed access to some benefit…namely my Medicare benefits, flawed as they are.


#12

I’d be willing to share. Brittle Type 1 , perfect candidate for the CGM, all my physicians support it,
Can’t get it covered. Out of pocket cost- for the Dexcom- $600.00, and 300.00 per month on supplies.
I could have a new sports car for that kind of money. Financially out of reach for me, Medicare declined it.
Spoke to rep at Medtronics, and she told me that they have more than several patients on CGM’s that are paying out of pocket for more that 2 years because Medicare declines coverage.


#13

Currently preparing for level 3 appeal, Administrative Law Judge after having had 100% coverage for the past 13 months. My Medicare Advantage plan stated they had made an error in the coverage. Longer story I’d be willing to share.


#14

Al - Curious what standing you might have against them when they claim to have made a mistake and are making corrections by refusing coverage. My Insurance company had been covering my Dexcom Supplies under Pharmacy coverage at a high CoPay. They agreed to supply October at the CoPay but claim they made a mistake and all Dexcom should have been treated as Durable Medical with a high deductible to fill before they would cover, (Still at a loss to understand how a sensor with a life of 7 days is considered DURABLE). So now I am effectively looking at Self Pay for the rest of this year.


#15

Has there been any progress on this matter? Anybody have any updates? I am hoping to refer a friend, who will be starting short term insulin shortly, to dexcom for a sensor. But, if it’s still hard to get coverage, I could purchase a new receiver, and gift him my old one, maybe.


#16

Hi @mohe0001,

At this time Medicare still does not cover CGM, and so many insurers don’t, either. However some do! Kaiser, for example, covers mine. Your friend needs to check with his insurance provider to know if CGM would be covered for him.


#17

I have a great interest in this. My Medicare, is still 2 years off and I have been using the Dexcom for at least 5 years. The thought of being without it terrifies me. Besides my Insulin, it is the most important tool I have. Why it’s not covered is beyond me. It’s a money saver that has kept me from accidents, the emergency room and lets me sleep at night. This policy has to change! Joyce


#18

I’m interested. Turned 65 this year and still working so I can keep my health insurance - that pays for my Dexcom CGM.


#19

For those of you using Dexcom and are afraid you can’t afford to continue using it when on Medicare, have any of you considered the Enlite? It’s $53.12 per sensor for customers who must self-pay. Guaranteed to last 6 days, and I’ve had one last up to 25 days. It isn’t perfect (is anything?), but mine work so well in my arm, it’s crazy. Of course it goes without saying you need a MM pump, but if you don’t have one now, perhaps you can have insurance cover one so that your ongoing (going forward) supplies are cheaper out of pocket. Medicare DOES cover the infusion supplies and with something like AARP Medigap, they are covered 100%. Just a thought. I am not going to get embroiled in a “but the Enlite isn’t any good” debate. Switching is just something I throw out there for those of you who can’t afford the very pricey Dexcom sensors.


#20

I have had T1d for 56 years and have been on Medicare for 2.5 years. Without Dexcom, I have difficulty detecting hypos and because I live alone, fear that I would become a dead-in-bed statistic. By the end of the year, my savings account will be gone because I have been paying out-of-pocket for Dexcom. What really drives me crazy is that I have worked hard to be well (and, serendipitously, thus save insurance companies money over the many years) and now that I am of Medicare age, all the best in treatment options cost me more. I would be delighted to participate in this endeavor - Emily, you can connect me with HCM.

Arlene