Insurance Coverage

Diabetes Technology Insulin Pumps
1

I know that most insurance doesn’t cover CGM. But I’ve heard of various people who have appealed their insurance rejection and gotten coverage (at least for the sensors, if not the transmitter/monitor). I’m trying to create a list of all the insurance companies that have covered CGM. If your’s has or you know of one that has, please post the name and address (if available) of that insurance company.

CGM is a great tool to supplement our BG control and the more we put pressure on insurance companies, the more likely it will start being covered.

2

Aetna HMO has for some.
I just sent mine in with Aetna PPO and got a request for more information…so in the follow up process.

From what I have read, it really depends on the patient and the overall condition…hypo unawareness, nocturnal hypos - hospital intervention, or just general intervention documentation was helpful for many.

Aetna is big on diagnosis codes…i think my dr wrote me up as 250.83 - which is unspecific manifestations (hypo unawareness is what i think the reason is)

I am interested in your research- you may have more luck on the yahoo group - because i dont think there are too many cgm users on tudiabetes.

3

Medical Mutual denied me but my wife’s United Health Care approved me. I love my cgms. Good luck

4

Hi, Ken. I’m submitting my request to Regence Blue Shield Selections right now. They say that it is not a covered benefit but it’s not on their list of we-won’t-even-talk-about-this items. I know there’s an official term that Lindsay from Medtronic-Minimed used, but I can’t remember what it was…It seems that the caseworker may have some influence on the situation, so we’ll see what happens. I’ll try to remember to update you all when I hear something.

Maura

5

United covers on a case by case basis. Minimed also told me that United’s coverage for New York State employees will cover the Paradigm Real Time System. We have been verbally approved three times but seem to have a problem actually getting Minimed to send out and bill for the Real Time System. Minimed wants a letter to them from the insurance company with very specific wording. Our insurance company then had to start the whole process again to comply with Minimed’s paperwork requirements. Still waiting for Minimed to receive the paperwork it thinks it needs and then send us the sensors and transmitter… Our insurance company said if Minimed would just bill them they will pay, but that is not good enough for Minimed. They will not accept verbal assurance that the sensors and transmitter are covered. We have heard that when Medicaid provides a code for these items next January, it will be a lot easier to receive coverage.

6

I just got Blue Cross of California to pay 50% of my receiver and 50% for a box of sensors for my upgrade to the Dexcom 7.

After I first submitted, including my doctor’s signed ‘Statement of Medical Necessity’ and an invoice from Dexcom marked “Paid”, Blue Cross asked for additional information - information which wasn’t asked for on the claim form, by the way. What they wanted was the ‘Procedure Code’ for the items. Based on advice read at the yahoo group ‘diabetescgms’ I resubmitted using procedure code E1399 for the receiver and A9900 for the Sensors. (The Diagnostic Code, BTW is 250.01.)

Two weeks later the check arrived.

I’m a happy camper.

Terry

7

That’s great. I’ve been too discouraged to try and push it any more with my insurance. But maybe I should. I’m only using my CGMS less than 1/2 time because I want the sensors to last a while before forking out another $350.

8

Hi, everyone. I’m 9 days into sensor use and still appealing my insurance company. No new updates on that front, but they did share 11 pages of research summaries explaining their position. It focuses on little to no change in A1Cs, etc. demonstrating that the effect is not statistically significant. They did say that a Star 3 study had not yet been published but they were following that in order to evaluate the information. Is anyone familiar with that study?

Maura

9

For Maura (Oct 26):

That’s an easy one if you’re using the CGMS to prevent dangerous hypos: A1c is an indication only of AVERAGE bG, and obviously, if you cut out vast amounts of time spent dangerously Hypo then your HbA1c will go up.

A1c is TOTALLY incapable of measuring/analyzing the variability problem, and any competent analyst knows this. So that objection is incompetent FUD. If the ball is now in your court, maybe send a short letter which points out this fact, and ask what COMPETENT criteria they’re using to say that the CGMS devices aren’t effective for the specific conditions which the FDA listed and approved them to treat.

In short: The FDA has found them to be effective. What specific persons at, or hired by, the insurance company are more expert than the FDA to label them otherwise-- and exactly what alternative treatment do they propose to protect you from Hypos, JUST AS EFFECTIVE AND WITHOUT SERIOUS SIDE EFFECTS, while you’re sleeping?

In your letter, via first class mail, ask that their response be returned by First Class mail in no more than 15 business days. They’ll understand the meaning of that request, (it’s threatening to use their response as evidence in Court), and might inspire them to stop trying to reject you with irrelevant, unqualified BS about “it didn’t lower their A1c’s”.

IANAAL, this are just my unqualified amateur thoughts. Consult with a lawyer in YOUR State, who knows YOUR relevant laws and can read YOUR insurance documents, to get qualified advice. (I think that this is a Civil Court thing, not a Small Claims thing.)

10

The “Star 3 Study” is here:
http://clinicaltrials.gov/ct/show/NCT00417989?order=1

They want to use this study for two reasons: First, it combines pumping versus MDI with CGMS, so the results are a quagmire of two different major therapeutic changes being made at the same time. But second, and even better for them, this study defines “glycemic control” as better/lower HbA1c.

Minimed is happy to do this study because it might get them a new indication: Pumping with R/T “improves control” for nearly anybody now on MDI. Right now, as you know from your prescription forms, you need hypo unawareness and/or extreme, sudden “dangerous” bG changes to qualify. (I remember those two, I don’t remember how many other checkboxes there were to “qualify” the pt. as an FDA-approved CGMS candidate.)

So Minimed hopes this study will allow them to sell lots more CGMS, without needing a history of dangerous bG occurences to qualify. They’re hearing “Ka-Ching, new indication!” But, for people who are already qualified as appropriate CGMS pts., this study is totally irrelevant. The study explicitly excludes everyone who “Has suffered two or more documented events of severe hypoglycemia without warning of impending low glucose levels, within the previous 12 months”. And study participants must be insulin infusion pump naїve.

If your situation already matches FDA-approved indications, “waiting for this study” is just more irrelevant BS. Even worse (for you), this study DEFINES “changes in glycemic control” as HbA1c. They excluded the people with Hypos, so of course they can use lower A1c as an appropriate stand-in for “better control”. But if you’re using CGMS to avoid frequent dangerous Hypos, the study is fundamentally irrelevant: Wrong inclusion/excusion criteria, Wrong method of measuring “results”, wrong everything. Totally inapplicable.

In a “Boston Legal” show last year, Denney Crane was talking with his son-- after winning the case against him, a case which his son SHOULD HAVE won easily. He said, “You lost the case when you let ME define the question.”

Same thing here-- if you let them define the question as “lower A1c”, then you almost certainly lose. CGMS doesn’t lower A1c in people who’s big pre-CGMS problem is frequent Hypos! That’s why they propose this study as “The Question”, and why you must take care to have “The Question” defined very differently.

11

An update on United. Oxford Freedom PPO by United does pay for the continuous sensors. You will need a letter of authorization from your endo. I’m not sure if it is still on a case-by-case basis but we were approved very quickly. In fact, the holdup was from Minimed. Minimed would not just accept the insurance company’s word that we were covered and put in a claim. They wanted the insurance company to write them an acceptance letter, specifically worded, before they would send us the sensors and put in a claim. United PPO had been saying all along they would cover us. We have received our Transmitter and sensors and will be starting up cgms shortly. I believe the endo authorized based on hypoglycemic unawareness at times (often does not feel lows, never when seated or engrossed in video games, computer or T.V.) and extremely variable, unexplained highs and lows. I have seen others with great need denied approval. Keep trying, keep documenting. If you have to go to the E.R. for lows, that may influence the insurance company in your favor, because it may cost them more for hospitalization than to give you the continuous monitor. Good luck. I’m rooting for you!

12

Thanks for the input. I sent my letter already requesting an expedited review. I am following up again tomorrow. In my letter I went point by point and countered their reasoning, including the fact that one tool they list as a potential alternative is no longer available on the market…the watch thing…Thanks for the tips. I’ll update everyone when I get more info.

13

My health insurance HMO is Harvard Pilgrim. I was not due for a new pump until April 2008. My doctor had told me that my blood sugars are very hard to manage and that I am the type of diabetic that the CGM system was created for. With that in mind, she wrote a letter of medical necessity and before long, my health insurance decided to cover the CGM pump for me…and early! It was October 07 a clear 6 months prior to my upgrade date and I was approved for a new pump…a CGM system! I have heard that Harvard Pilgrim is a leader in the insurance industry as far as covering this and now I have proof. I had my pump in less than 2 weeks from the day I even mentioned it to my doctor. At that appointment, I mentioned how anxious I was to have April 08 roll around and how I hoped health insurance companies would cover the CGM pump by then. MiniMed did call me once the pump was sent out and they did tell me to follow up with my ins. company. They stated that because the transmitter/sensor system is so new sometimes the insurance companies do not cover it under the Diabetes category. Sometimes, it is under the “durable medical equipment” category. The reason this is important, the rep told me, is that under the diabetes category I am covered whereas under “durable medical equip” I am only covered to $2,500 a year. This would cover approximately 6 months of sensor supplies. When I called Harvard Pilgrim, I was told that it did successfully go under the “diabetes” category but because the CGM is so new it is still under evaluation and the coverage could change. I am completely satisfied with that and will keep my fingers crossed. I think that as time passes, the insurance companies will truly see the value in this device and will continue to offer coverage for it.

14

Insurance Won (Dexcom “Seven” Sensors)!

Anthem BCBS of Nevada just changed my Sensor claims (Dexcom) from “pending” to “Out-Of-Network Deductible”… so it’s looks like I’m being covered! (Out-Of-Network only pays at 50%, and the deductible is big, but I’ll be getting quite a few $$$ of assistance next year.)

Minimed is in-network, but didn’t really work for me. If J&J “Animas” releases a product in a year or two, they’re in-network too.

I was never rejected and didn’t need to appeal, but my Endo Office probably submitted historical records which made the effectiveness VERY obvious in my particular case.

15

Regence WA denied my appeal stating that the device is investigational and that no well-designed studies support results that are statistically significant. Is there any chance of getting info from your company about why they are funding the devices? Maybe there’s a number a randmon person can call? Also, does anyone have a list of companies that are covering it? I am just thinking of the peer pressure approach or at leat having the knowledge for myself…Thanks!
Maura

16

Hey Maura, did you send a letter asking them to name, in writing, the specific person(s) whom they claim to be MORE EXPERT than the FDA panels which approved Dexcom and Minimed for general use?

With the clincher: “And explain exactly why the FDA panel process is invalid, and you get to treat these devices AS IF they were still in PMA status.”

17

My appeal was approved… Aetna PPO covering Dexcom and sensors at 90%.
I had 15 pages of documetation with my appeal—a letter from me, 2 letters of medical necessity from my Endo, 3 months of meter reads prior to dexcom, corresponding lab results with A1C’s—3 previous, 2 post.
I think Aetna is still case by case…they will deny and then you have to appeal. My first appeal was approved.

18

Mollie,

I am in the proces sof fighting Tufts who has rejected me for somewhat silly reasons. Can I ask you if you are comfortable sharing some of your letters? I would be greatful. I am not even sure where to start!

jjflannery@comcast.net

19

In January, Animas and Dexcom announced that they would be collaborating on a combined system. So maybe they will have one in a year or so.

20

Unified Group Services
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800 -291-6691

Administrating the contract for Westfield Washington Schools

Medical review done by:

Individualized Care Management of
Lafayette IN