Insurance approval for Dexcom CGM

My endo told me that I would not likely be approved for a CGM as my A1c is ‘too good’. 6.5.

So- sugar is not staying in my system long; meaning I test a lot and bolus/treat highs lows gently and quickly. BUT I know that I could be doing better in controlling these spikes in the first place.
Is it true that a < 7.0 A1c can keep you from getting insurance support? Anyone have any stories to share regarding getting CGM as I further investigate getting one for myself in the new year?


It depends on your insurance, but many are willing to provide the CGM for patients with an A1C less than 7 if they have hypoglycemia unawareness, if there are lots of lows in the middle of the night, if there are too many spikes and falls. Keep good records and push your doctor to submit the paperwork, they can’t make a decision either way until they see your documentation.

I agree with Rebecca. Keep detailed records to show the swings in your BS. My A1cs were in the 5s and I was approved. I am hypo-unaware and I was having a lot of swings. My insurance denied a CGMS (I had the Navigator before the Dexcom) but I appealed it and won. I sent them detailed logs and pointed out all the swings. Current studies show that those swings are just as bad as staying high all the time.

I don’t know. I provided my insurance company with a lot of information on my hypoglycemia awareness. Plus, they’ve paid for about 10 hospital visits for hypoglycemia in the last year. They told me that my A1c was too good to need a Dexcom though. (They also rejected two appeals.)

I think it largely depends on the insurance company. Mine kept citing information from 2000-2002 as evidence that CGMs were not good enough. When I pointed out that they’d advanced, they managed to get some paid doctor (without a diabetes specialty) to say that CGMs were unnecessary. (Obviously, I have a lot of anger towards my insurance company.) But my insurance company is not very big, so I don’t think anything would have convinced them to pay for a CGM - they viewed it as too expensive. You insurance company might be larger and might not have that problem.

I had to keep a detailed record for my ins company before they approved me. And since my levels are all over the place, they approved me.

As rebecca said, it depends on the ins.

You should try. I just won my appeal. My insurance will pay for type 1 but not for type 2. I have horrible lows at night. It took 3 months but I am on day 6 now and have had 2 nights of bad lows that it has helped me with.

Your ins. company sounds penny wise and pound foolish. A Dexcom and supplies over the course of a year certainly costs less than 10 hospital visits!

Did your endo help you build your case for needing one? They could explain that your low A1C is not necessarily an indicator of health… it can also be an indicator of life-threatening hypoglycemia!

If I were you, I’d file a complaint with your State Insurance Commissioner.

I’ve been on the dex since November 9th. The paperwork went in on October 16th and approved on October 29th. So now its pump time and the approval time can be different than it is for CGM

My insurance company approved mine in 2 hours. I have a great endo who knew how to fill out his part of the paperwork. I had to send logs showing BG of less than 55 and tell them about visits to the ER in the last 6 months or year. My hypoglycemic unawareness and high A1C (over 8, I think) came in handy.

We also won an appeal for my son. His A1c was just over 7 (7.2?) but since many sources state a goal of under 8 for kids, it was still too good. And our insurance has a blanket policy of not approving them for kids anyway. I agree with what others have said - it’s worth the fight. It took 6 months for us, but we did get it (although now, 5 months later the insurance finally actually paid for it).

I was approved two years ago by Blue Cross and my A1c has never been above 5.3 - I have been in tight control for the past 30 years. My doctor’s prescription for the Dexcom was based on risk of hypoglycemia, which is real for anyone who is in tight control. Good luck - hopefully you can convince your insurance that it makes sense for you.

My A1c has been less than 6.0 for many years, but I was still having some hypos as low as the 30s and 40s that concerned me. My endo wrote a letter to approve the Dexcom and my insurance approved. Other diabetics have reported that having thes low blood sugar numbers resulted in the approval of their CGM. My insurance company wanted my records of my blood sugar numbers for the previous six months. I have been keeping records for at least 20 years, so that was no problem. I record my daily meter readings, carbs eaten, insulin dosages, etc without fail. I am convinced the thorough records resulted in the approval.

Now my health insurance group has changed plans, and I was forced to give up my plan that was covering my Dexcom. I will not know until early 2011 whether my CGM will still be covered. I have not used a sensor for about two months. I am saving my sensors for special occasions, like when we go on a vacation or take any kind of long trip. That is when I get the most good out of my Dexcom.

Awesome! thanks for all the input!! I am certainly going to go for it. You have all helped me know how to prepare for worse case scenario/appeal. Am now investigating (well, when the holiday passes I will) if it will be Dexcom or maybe Medtronic? Am using Animas ping and that works with the Dexcom. And is also waiting for FDA approval for the two devices to talk to each other. My Ping 'contract' isn't up for another 1.5 yr. So have to think about this. Likely to go with Dexcom for the hope that it will be approved. Plus, I don't much like too much change with gadgets if I can help it!