I have regular Medicare. Have had many fully favorable decisions at the ALJ level. AdQic appeals the decision to the MAC(Medicare Appeals Council), saying that the ALJ made a mistake of the law. MAC reverses ALJ decision and the last step is an appeal in Federal District Court at a cost to me of $30,000 or more. The appeal process is a joke. Took three years to get to the last level of appeal. AdQIC is a Medicare contractor. Only fair level is ALJ level and they get shot down!! I had video- teleconfereces fot the ALJ level.
I have been advocating for awhile on CGM coverage by Medicare. Even though I am not yet on medicare, I plan on someday being on Medicare. I have personally talked to my US Representatives and will talk to my US Senators when the time comes. I have research and understand the political issue which is too long to explain the multifaceted issue here.
I have also been working with my endo on coverage of CGM on some insurances policies in my state.
I would be glad to take an active role and advocate. You have my email and phone number I do believe. If not inbox me.
My CGM denial from both my Medicare Advantage Plan and MAXIMUS (Medicare contractor) stated that a CGM was a"precautionary" device and therefore is not covered. I have been unable to find a definition of "precautionary " in any of the Medicare material.
- Have any of you been able to find a Medicare definition of precautionary? If so, please send me a link.
- Have any of you who have appealed at the next level -Administrative Law Judge- challenged the labeling of a CGM a precautionary device?
Emily, I, too, would be happy to speak. Not sure it would help because back in the late 70s, I believe, I flew to St Louis to testify before a committee regarding the need to protect diabetes in the workplace. The ADA was passed, but didn’t include diabetes! Anyway, can probably help many senior IDDMs get CGM covered. I just won my appeal, third time I had to do that, but I have all the documentation that others can copy & use that makes the MA plan afraid not to approve it.
Thanks for adding your voice to an important issue.
Does that mean you have actually gotten coverage, or is your latest appeal under review?
Yes they can contact me.
I started on the Medtronic CGMS in 2006 when I had private insurance (with Medicare as secondary). I originally paid out of pocket but after about a year (perhaps less) BC/BS started paying for the CGMS. We changed insurance twice (Oxford and then GHI) and they both continued the coverage. In 2012 Medicare became my primary insurer and eventually I ran out of MM sensors. In 2014, after pumping with Minimed for 21 years, I switched to a t:slim pump and the Dexcom CGMS which I pay for out-of-pocket. I have signed petitions and written to my senators and representative many times regarding Medicare coverage. So yes, I am interested in taking a more active role in this effort. I am a feisty, active octogenarian. What can I do to help get this coverage?
I have won numerous appeals at ALJ Level. AdQIC appeals ALJ decision to the MAC(Medicare Appeals Council) and you reply to MAC. MAC rules in favor of AdQIC and you go to the final step which is to appeal the MAC decision to Federal District Court. This fifth level of appeal will cost upwards of $30,000. I did not go forward to the fifth step. There is a case from Eastern District Federal Court in Wisconsin where the court said that CGM can be considered. Case is Whitcomb v Burwell. I
@SueL, thank you for sharing your experience and fighting for yourself and others in the same boat (or soon to be!).
From what I have been able to find out from other news sources, Whitcomb v. Burwell did go to Federal District Court where they remanded it back to the ALJ, with a ruling that the MAC erred on one of its reasons for reversing the ALJ’s previous affirmative (for the plaintiff) opinion. So in my mind, that just pushes the whole thing back to the fourth level of appeal.
United Health Care (the Medicare insurer in this case) has until December 14 to request a further MAC review, according to what I read.
Can you add anything to my understanding?
Today I published a blogpost sharing my letter to Senator Al Franken and encouraging others to take advantage of the opportunity to work with HCM Strategists. Thanks for letting us know about this, Emily!
Emily, I’d love some assistance in getting Senator Tammy Baldwin, D-WI, to get on the co-sponsor list. I’ve sent her emails twice and both times have been told she’s not on the committee. That tells me that my request isn’t reaching the right person. I worked on Tammy’s campaign when she was running for Congress. Sue and I have contributed to her campaigns. Our Rep. Mark Pocan, D, WI, is a Co-Sponsor. It’s time for Tammy to get on-board. Please connect me with HCMI. Thanks!
I thought that HHS Secretary Burwell had a certain number of days to appeal and if she did not that the ruling stood. I also thought that the time limit had passed.
@Richard157 put this up earlier:
That article says United Health Care has until Dec. 14 to appeal. However, even if UHC does not appeal, it appears that you and others will still have to go through the same wringer, since the Federal District Court did not make a direct ruling, rather the court sent it back to the ALJ/MAC process for reconsideration, saying Secretary Burwell was in error on "ONE of her conclusions (emphasis mine)."
Thanks! I am aware that I will still have to go thru appeal process, but I probably won’t appeal on sensors anymore. Not worth my effort. Can’t afford Federal Court.
To my naive mind, after a ruling like this, Secretary Burwell should direct CMS to approve CGMs based on cases similar to Ms. Whitcomb’s.
Then you and others could pursue your golden years, instead of pursuing a long drawn out process that creates unnecessary stress, paperwork, travel, record-keeping, paying for attorneys, stress, throwing money away, the gnashing of teeth, crazy unseen hypos and hypers, less time in range, the deterioration of your health, oh and did I mention stress?
Thanks again for responding and I wish you success in your appeal(s)!
I’m kind of obsessed with this issue and would like to help however I can. I am 49 years old and have had diabetes for 40 years. Using a CGM has been an insanely amazing upgrade from using a meter alone, and, yes, my control has improved too.
I am already in contact with HGM. I was successful at the Administrative Law Judge Level for CGM approval and it was not appealed. A procedural step report was prepared by me to share with other individuals. At the moment, I do not have a blog posting. Should you desire to review the four page report, please feel free to drop me a line.
Wow! Congratulations @Dan23! You are the first person I have heard of to essentially win your appeal. Maybe send Emily a private message, so we can get the appropriate info out to others who are in the midst of their appeals process.
I have been successful with 4 ALJ appeals for CGM, but all of them were appealed.Would love to see the procedural step report you prepared. Thanks
Hi Emily, they can contact me. I can also provide an economic or financial justification for covering CGM - it a helluva lot cheaper than a run to the emergency dept!