I talked to the rep. at Medtronics, who by the way, I have dealt with before and she is a lovely person.
Her name is Molly and she has been diabetic all her life and she just started on the CGMS and she absolutely loves it.
We talked about how we have such anxiety as we no longer can recognize highs and lows and how she gets all nervous and not sure if it is a low or just being nervous and unsure.
I told her how I am afraid to move sometimes, doing stairs, or long hikes, because of fears of lows and she stated she was testing almost 15 times a day.
Oh, that is bad news, I’m very sorry. But don’t give up yet. I hope there is an appeal process you can go through, and I’m sure your endo is backing you up, right? Can you calculate the savings to them in test strips, and extrpolate it out to show a big difference? Of course you’ll need some strips, but not as many.
My husband said the same thing about comparing costs and I do have an excellent letter that a friend of mine used to get his insurance to pay. He bought his without running it by his insurance they denied it and yes there was an appeal process with his letter and even a conference call with the insurance companies and their MD’s. My endo backs it and has even worn it to see if there is a lot of discomfort. He was even on the local news and he has one of his ped patients on it. Everything with diabetes is so hard, especially after 40 years and now suffering from hypoglycemic unawareness and avoiding exercise just because it is easier.
I am not whining just disappointed as I can so see the help of this device in my life. Like the Medtronics rep. said she would test, but in as little as 1/2 hour her bgs could drop and she would not know, that is where the anxiety comes in. I have it everytime I shop or do anything physical. I would love to walk 18 holes of golf again.
I called Medtronic today and found out they don’t even submit to insurance companies requests for the CGMS if they know that the insurance company will not pay for the CGMS. I gave my lovely Molly a bit of my mind and stated how would the insurance companies even know the demand or desire of this device. I am sure the insurance companies love this and then know that most people will not persue. So I contacted my insurance company with this. I am not sure how to go about this, but I am trying to get the MiniMed Paradigm® REAL-Time Insulin Pump and Continuous Glucose Monitoring System, which MiniMed upfront knows Coresource/Aetna is not covering at this time, so they did not and will not submit anything to them. How do I go about appealing something that was never even submitted to Coresource and denied? I want this medical device to avoid known complications of diabetes, by obtaining tighter blood glucose control.
This was their response:
To the best of my knowledge, we would not deny this device. However, medical necessity and appropriateness for the device would require review. These devices are meant for those diabetics who cannot, by standard means, keep their blood sugar under control. If documentation with her medical providers indicate that standard measures of maintaining blood sugar levels have not worked, then the new device could be deemed as medically necessary.
However, if she is wanting this device because it’s easier, that will not be approved. These are very expensive.
Let me know if you need anything else. My recommendation would be for her to submit documentation and medical records from her providers indicating why she needs this device. We can then render a predetermination prior to her purchasing this deviceI have a lovely letter just about finished to begin the battle.
Karen, your situation sounds similar to what I went through to get my first pump, back in 1998. The insurance company wanted proof that injections were not working. I was still in college and on my parent’s insurance then, but we fought for months and eventually got my pump. It took numerous phone calls, letters from me, bloodsugar records, and letters from my doctor. Just keep your determination and hopefully it will work out! I’m just getting started with trying to get the new pump and CGMS, so I may be in the same situation again soon…
I would love to get the CGMS and my CDE keeps pushing it, but I can’t afford it. My pump is only a little more than 2 years old so I would also need the pump upgraded as well as the sensors. I’m hoping that by the time my warranty runs out insurance will be more willing to cover it. Right now I test my BG 10-16 times a day. I am also hypo unaware.
I have to say that just having my pump without the CGMS has been a tremendous help. The money my insurance spent on it was worth it to them because I haven’t had a single ambulance/EMT visit or ER visit due to lows/passing out since I went on the pump. And my insurance was great about covering the pump, approving it with just one phone call from Minimed.
My gripe against Molly was that she did not present it to me that she contacted my insurance and that they denied the claim. I had to call Molly twice to learn that they don’t even submit it because they know upfront, Aetna will not pay. I thought Molly had submitted then I would get notification from my insurance of the denial, but that would never of happened, if I had not questioned Molly.
Speaking with my endo about the various CGMS devices in March, he told me that the FDA has not yet approved any of the devices due to lack of the companies that manufacture them going through the rigorous FDA guidelines, whatever they are. My understanding is that insurance companies will not cover anything if it is not FDA-approved to be used in the treatment of x condition (in this case diabetes, of course). Once a company gets their product through the FDA guidelines then they should be covered by insurance, but it may be months or years.
If you read the FDA approval of the Medtronic Minimed device at http://www.fda.gov/cdrh/PDF/p980022s011b.pdf , and the read the 3rd sentence of the 1st paragraph of section II, titled “Indications for Use”, you’ll see the following sentence:
“Values are not intended to be used directly for making therapy adjustments, but rather to provide an indication of when a finger prick may be required.”
This sentence is why insurance companies don’t pay. From their perspective, they cover and encourage the finger stick thing, therefore an instrument that indicates a finger stick may be required is not necessary. It is up to the manufacturers of the devices to get the FDA to sign off on this device being used instead of finger sticks, rather than in conjunction with. Don’t blame the insurance company, blame the manufacturer who didn’t get the approval to replace finger sticks, or of course the Republicans who run the FDA
I realize it is still in its early stages, but I feel like my life is passing me by because of my diabetes, sometimes I am afraid to move. Hypoglycemic unawareness and tighter control with the pump has made my bgs better but not my freedom to do what I want when I want. Hard for me to explain, but my life was easier when I was on two shots a day and kind of in the dark about things. With tighter control comes hypoglycemic unawareness and therefore my need and want of the CGMS even if I still have to test my bgs manually occasionally. I know the device will improve over the years, but I don’t have any more years to wait.
Thanks for responding and I do understand all sides.
I understand your point, I am a Type I and have had some whopper low BG’s. To be clear, I am on your side. Unfortunately, these devices do not yet have the FDA sign off required to push the insurance companies to do the right thing.
Again, dang Republicans, holding back stem cell research as well as CGSM, next thing you know they’ll ban insulin for 1) being against God, and 2) not promoting enough health insurance industry profit… (My humor may be a bit odd – I hope you realize this is a poor attempt at political humor!)
I understand your odd humor. and I understand why insurance co.'s are not jumping on the bandwagon with the CGMS, but they will.
Glucose meters used to cost $300.00 and now you can get them for free, so I am sure the price will eventually go down, but I don’t want to wait. I have had diabetes for 40 years and have only been pumping for 4 and now regret that I was such a chicken $#i+ for waiting to try the pump. I don’t want to wait on this.
My insurance company currently pays for 400 test strips a month for me. I would gladly take 100 strips and the CGMS. Even if the CGMS numbers aren’t exact, you still get the trends and can tell if you’re going too low or high.
I thought that insurance isn’t covering it because there are no proper billing codes yet. Insurance companies use the codes that Medicare uses and since Medicare doesn’t cover CGMS systems, there are no codes yet
Hi everyone! I am new to the website. My son is 6 1/2 and was diagnosed January 22, 2007. He is curremntly a “pumper” and everything seems to be going well. My wife has quit her job and started a new one as a full time pancreas for Caleb. He attends a private school without a nurse so my wife has become his caregiver at school as well. I just wanted to say “hi” and get aquainted with the website.
So far, everyone we have come in contact with who has diabetes or knows someone with diabetes has been so supportive. That includes Molly at Medtronic. She has been very helpful in getting started with the supply side of things. I also grew up with a girl who had diabetes, She is actually the one who recommended this site. It means so much to know that yo are not alone when you are new and dealing with your own emotions, your spouses emotions and your childs emotions. I hope to learn a lot here and would like to be able to offer that same support to anyone with a child who has diabetes. Thanks for allowing me to join in.
Good luck with the battle with Aetna. I haven’t even tried going through Aetna ( my insurer) for the sensors yet. Since 2000, Aetna has supplied me with a Minimed 508 and a 512 & the supplies with a minimal co-pay. I decided about 3 or 4 months ago to bite the bullet and just buy an upgrade to the 522 pump and the Transmitter/sensor kit. I have paid too high a price for too many lows. I wanted a better way to live.
So far with the sensor, it’s always warned me before low blood sugar gets to be a problem I can’t take care of. One thing I learned “very unofficially” from my pump trainer was that many, many users switch sensors after 6 days, rather than 3 days. Instead of a box of 10 sensors lasting me month, they last me two. That was a very nice surprise.
and I understand why insurance co.'s are not jumping on the bandwagon with the CGMS, but they will.