I see many people on TuD mention they use a CGM. However, I've been reluctant to even pursue it because a co-worker who has been T1 for 30+ years has one, but she told me our insurer refused to cover it so she pays out-of-pocket. I'm just curious how many of you using a CGM have it paid for by insurance. For those who do, was it difficult to get approval? Did you have a specific reason that helped, such as hypo-unawareness? I've finally made the decision to start the process with DexCom to see if I can get insurance approval, so any tips would be much appreciated.
If you end up paying for it yourself, you don't have to use it all the time. You can use it
1. To fine tune your basal doses, carb factors and insulin sensitivities.
2. When you are sick.
3. When you are on vacation.
4. To trouble shoot meals that cause very high BGs.
5. Track your Dawn Phenomenon.
Good luck with your insurance. I envy people in the US that have access to the DexCom. It's rated very highly by almost all the people using it.
I am in the approval process for a Dexcom G4 right now. It is supposed to be approved from start to finish within about 2 weeks. They pay 80%, I’ll pay 20%. Supposedly the approval process is easy, it has been so far. Dexcom did have me submit 2 months worth of blood sugar logs, so that might be a requirement with some insurers.
My insurance covered it, but I do think I had to submit a few weeks worth of blood sugar logs. Additionally, I think it helped that I was becoming somewhat hypo-unaware and that I also was planning on getting pregnant. They approved it pretty easily and cover it at 80/20 (they pay 80, I pay 20). Good luck! I hope you are able to get approval!
Mine paid for it without batting an eye. I only used it for a few weeks though , wasn’t for me.
It was helpful as a learning tool in those few weeks for me though… And I may occasionally revisit its use in the future if I need to figureout new trends, etc
With me, I told the doc I wanted it (was working towards 1/2 marathon...), she told Medtronic and they did all the work. I had to do a log to get the pump but the CGM, they just did my pump log so it was very seamless. I dunno if the marathon actually mattered. I always have had enough "hypos" in my charts to "count" but I have symptoms and probably 90+% of them are "drift" hypos in the 60s and, to me, not that big of a deal.
We had no problems with insurance (my daughter was 12 at the time), but the endo did have to supply 3 months worth of logs. It wasn't a problem because we have to supply written logs at every endo visit. There was a holdup because of faxing issues between the endo's office & Dexcom, but we still had it in hand within 3 weeks.
If insurance denies, you can always appeal.
It's been a few years since I have mine so, I'm not sure if the requirements changed with my insurance. But, from what I remember I needed a letter of medical necessity from my doctor, a log of BG's, hypo-unawareness and T1. I was denied the first time but, that was only because of a coding error. Medtronic's did all of the paper work and in no time I had my CGM.
Good luck!
My insurance covered mine in total and required no logs or anything. I was actually kind of surprised because I'd heard it was difficult to get coverage. I'm not hypo-unaware, but I do get a lot of lows. so I was prepared to have to prove my need for it. In the end, I told my CDE I wanted it, she was unsure if I'd get coverage but said they'd start the paperwork, and insurance said, no problem, you've met your deductible, CDE says you need it, you can have it.
I don't have a CGM, but as soon as the Vibe comes out I will be getting it. I'm not expecting mine to be covered, most Canadians I've spoken with have to pay for theirs themselves. I've only met one person who had hers covered. My endocrinologist recommended that when I get it, I use a CGM similar to above, just to troubleshot and fine-tune rather than all the time.
I am lucky that I worked for the government my last 8 years and have Medicare as primary and fed based insurance as supplement. Therefore, my cgm was paid for in full by my secondary insurance. Medicare does not pay for cgm ever. I pay double insurance premiums (Medicare and BCBS) so I do not have copay. I pay the equivalent and more though, through premiums. But in return, all my med supplies and pump and cgm are paid for. I do use the cgm all the time but could see using it 'as needed' if necessary.
PS. I do have several oral meds and I do have copay for them. $75 for brand names (90 days), which is what I mostly have.
Mine is covered 100% by insurance with no copay or deductible. I have hypounawareness and that was pretty much all they needed to cover it. I did not have to supply blood glucose logs or anything. But as others have said, just because you have a CGM it doesn't mean you have to use it every single day. I choose to because I find the information helpful especially when I exercise, but I got a shipment of 12 sensors in February and I still have 6 of them left. They will probably expire before I actually get a chance to finish them.
I had a dexcom last summer. My endo communicated with my insurance to have them approve it. I was having hypos that were low enough and I think being type 1 was enough anyway, I don't know what the communication was exactly, but I'm not hypo unaware most of the time. My insurance didn't cover everything though, I had a $30 a month copay for the sensors! And I paid abut $200 for the dex, but I think some of that was refunded with a coupon/promo. I ended up returning it though since I couldn't tolerate the sensors in me, they were painful, causing muscle spasms and site inflammation/swelling and I was having an allergic reaction to the sensor itself and the latex in the glue, even with something in-between my skin and their glue. The dex was also mostly not accurate for me, it was beeping me to wake me up saying I was 150 when I was actually 50. I had some readings that were 100 or more points off with only 2-3 accurate readings per day. I guess I'm one of the unlucky ones who it just didn't work for. I hope it works for you.
My Doctor sent a letter of medical necessity to UHC and said to me it's a wast of time they will never approve a CGM (this was in 2008) It only took me 6 days to get my CGM they approved it without any response and since then I have switched to BCBS Anthem and they have covered my CGM and pump without question. Both of these policy's pay 100% after the first $1000.00 DMG so my OP is 1k each year for my pump, CGM/ sensors, and supply's.
My insurance did not hesitate and I was covered at 50% (PLUS system). I paid $150 or so (don't remember) for my doc's time to fill out the paperwork. My impression over the years is most insurance will cover (for T1) but of course it really matters what your DME copay is. Some people have fantastic coverage and pay only 20% or even 0%. If you are on pump as well, you pay hit your OOP maximum and thus your bottom-line cost for Dexcom could be affordable. You could consider waiting to buy Dexcom in the same year as new pump so that you hit your OOP max. In any case, Dexcom is very good about calling you and explaining your bottom-line cost before you decide. I will say Dexcom is a poor value for part-time unless the transmitter battery can last substantially past its 6 month life-time. I love Dexcom when I can afford it and almost anyone would benefit from trying it at least once.
Clare, your sensors will work well past the expire date, or at least mine did (4-6 months past).
Thanks Don, the 6 I have left expire in late September but since I am getting more than more than 2 weeks out of a sensor chances are these will be very close to expiring by the time I use them up. But it is good to know they will work past the expiry date.
I agree with Sam. I would consult with your doctor regarding documentation of your low episodes. I would have no trouble documenting two episodes of BGs < 50 that threatened my or other's safety. I would persist and be the squeaky wheel that gets the oil, err CGM! Let their denial letter serve as your roadmap to qualify for coverage.
Sorry, I didn't know. While your control is excellent, you do take exogenous insulin. I would never wish you hypos < 56 but insulin is notorious for driving BGs hypo. Has there ever been a case where a T1D taking insulin never goes below 50?
Even your case, where you appear to continue to have some useful pancreatic function, it's probably only a matter of time until more severe hypos occur. Again, I don't wish them on you. If they happen, keep good records and apply again.
You're doing a great job; keep up the good work!