Hypo Unaware T1 - Aetna says yes to CGM for long term usage?

My endo had a peer to peer discussion today with the Aetna Dr Thomas Sutherland—he reviews all the precertification stuff. The conversation was called so my endo could ‘convince’ Dr Sutherland at Aetna, to pay for long term continuous CGM usage. He pulled my case number and said something like, ‘I dont mean to stop you in your tracks, but Aetna has change thier policy. For T1 diabetes that suffer Hypoglycemia Unawareness, Aetna will now pay for long term CGM usage. He added that since there is not a distributer in network, that the supplies would be covered as In Network.’

I will have to resubmit some older claims, but supposedly, future claims should be approved upon first submittal. Time will tell. But is does sound hopeful.

(Aetna did pay for my Dexcom Receiver, Transmitter and first 5 boxes of sensors upon first appeal…however since then they had stopped paying)

I went thru precertification—who refered me to the Dr to Dr talk.
I really dont know what my next step is, planning to wait a couple weeks to see if i get a new EOB with claims paid. If not, i will send in for appeal and refer to the conversation.

At this point, I would recommend calling aetna precertification and get the ball rolling.

Great!! I am on hold with Aetna as we speak (12 minutes and counting).

Aetna HAS changed their clinical policy bulletin! It now states:

Continuous Glucose Monitoring Devices:

Aetna considers continuous glucose monitoring devices (e.g., MiniMed Continuous Glucose Monitoring System, Guardian Real-Time Continuous Glucose Monitoring System, and the DexCom STS), which are used to continuously monitor diabetic persons’ blood glucose levels over a three-day (72-hour) period, medically necessary for persons with type 1 diabetes who have either of the following problems in controlling blood glucose level, unresponsive to conventional insulin dose adjustment:

repeated hypo- and hyperglycemia at the same time each day; or
hypoglycemia unawareness.

No more than two CGMS monitoring periods are considered medically necessary within a 12-month period.

Aetna considers the long-term use of continuous glucose monitoring devices medically necessary as an adjunct to fingerstick testing of blood glucose in persons with type 1 diabetes who have had recurrent episodes of severe hypoglycemia (blood glucose less than 50mg/dL) despite appropriate modifications in insulin regimen and compliance with frequent self-monitoring (at least four fingersticks per day). Long-term use of continuous glucose monitoring devices are considered experimental and investigational for all other indications. Note: For long-term use for recurrent hypoglycemia, the CGMS monitor must be used by the member on a trial basis for a minimum of one month (30 days), but not to exceed two months. The trial period will be paid as a rental. The trial period must be monitored by the physician to determine the effectiveness of the CGMS monitor. For coverage of a purchase, the physician must determine that the member is likely to derive significant therapeutic benefit from continuous use of CGMS over a long period of time. The physician’s records must document a reevaluation of the member at the end of the trial period, must indicate compliance with the use of the CGMS monitor, and the results of the use.