I, just this last week, got Kaiser Permanente pacific/hawaii region to approve my cgms, without any hassel or appeals. all i needed was a letter of medical nessecity recomendation for the cgms from my doctor. my letter the doctor wrote basically stated that she was reccomending the cgms for me because i had trouble with insulin dosing because of gastroparesis and also had erratic bg’s and hypo unawareness. it also mentioned how cgms are now being covered by medicare. that was pretty much all it took. my doctor faxed the letter over to our durable medical equipment department and within 2 days i got an answer back from their review board. i talked to minimed and confirmed that my insurance had indeed placed the order through and i gave the ok for them to ship it out to me. kaiser put in the order for the whole thing, including a 3month supply of the sensors! ;D come tomorrow, i’ll be knocking at the fed ex counter for my new mm cgm system! horraaayyy!! . i’m really anticipating this thing being able to help me figure out and proactively tweak my bolus timings and tracking of my bg spikes; not to mention the sense of security one gets from high and low bg alerts!!! no more unpredicted highs and groggy awakenings from prolonged night time hypos!, this thing should help a lot with the GP bg mysteries.
Which monitor did you get?
Kimberly
Chloe’s Mom
After fighting for 9 months and 3 appeals, my husband was finally approved for the CGMS. Our ins is Keystone Health Plan East in Philly. They denied to the bitter end until our appeal went through the Dept of health to an outside"independent entity" which (after 3 months) recommended approval. He has been using the MiniMed CGMS for 2 weeks and what a difference! I recommend anyone fighting with their insurance to print out EVERYTHING ever printed and published on any CGMS, even Dr owned. Find articles online from Medical Journals, just the abstracts, if necessary (since most full articles cost alot of money) The stack of printed articles I sent was 4" thick, literally. Send proof (ie: bills) of 911, and/or ambulance calls and hospital (ER) trips. Fight, fight, fight!! You can WIN! Btw, the ins. cover everything needed for the CGMS.
Hello Ken, I have BS, I was told that they do not cover CGM systems, I got a letter of necessity from my endo and MAILED it to BS, they turned me down, I MAILED the same letter back 3 times and of the fourth time they paid for the whole pkg.
Al.
Empire Blue Cross Blue Shield covers mine. For a 3 month supply I pay about 70 bucks out of pocket. I had a traffic accident due to hypoglycemic unawareness. The doctor told my insurance it was necessary and I haven’t had any problems with them at all. I’m doing much better now and the CGMS has helped me regain much of my hypoglycemic awareness.
Kevin
I have cdphp and I had to write a letter and they covered it I had a deductible to for it being Durable Medical Equipment and there is copays for the supplies also and the sensors.
I have Oxford Freedom Plan (new York), and I am expecting a denial from them. My A1C has consistantly been 5.9-6.1 for the past 4 years. I have had the minimed pump for about 2 years now, and had no problem getting approval for the pump. I hope my insurance sees that I am a very detailed a careful diabetic and will be given teh opportunity to take it a step further and keep myself healthy with the CGM… I will post my progress.
I believe that more insurers over time will recognize CGM as a medical necessity. I just got full approval from my medical insurer for CGM. I work for a hospital system in SW Florida (Lee Memorial) and we self-insure. I had to work with the Health Advocacy Dept, Medtronic MiniMed, and my doctor to get reviewed and ultimately approved. From my perspective it was way too much effort, but now I do understand the process and guess there are people out there with more serious diseases than T1 that work even harder to get coverage for treatments. Thank God I have coverage now. MM and my doctor were great to work with. If anyone is going through a review process with their insurer and want to see what was contained in my medical necessity review letter just send me an email and I’ll outline the data points that was in it.
I have CIGNA, and they were denying me up until 2 weeks ago, when they suddenly approved it for me. Minimed said they recently sent out a new round of CGMS research results to insurance companies, and they are starting to pay attention. So if you’ve been denied before, give it another try and keep trying. I have also heard that Blue Cross is approving them more and more. I imagine all the big companies will be on board by next year. I just got trained on it last week…going well so far!
I am presently on my third appeal for a CGM. My insurance is PEHP (Utah) and they are really being awful about it. Gerhart, could I get you to send me a copy of your medical necessity review letter? My email is cjensen780@msn.com. My doctor is very upset that they are not taking his word (and that of my ophthalmologist too) that this is needed. I have had two car accidents (years ago) due to hypoglycemia unawareness. I keep wondering what proof my insurance company needs to convince them that I need this! For the third appeal, I did send them the copy of the Journal of Medicine article on the clinical trial that was funded by JDRF. I am considering a class-action lawsuit. Thanks.
From my rejection letter from Kaiser Permanente Northern Cal.:
“According to the Durable Medical Equipment (DME) guidelines, this item is covered for members who are insulin-dependent diabetics and have one of the following: 1) Failure of 3-7 day diagnostic continuous glucose monitor use to reconcile hypoglycemia and subsequent treatment plan change; 2) More than 2 episodes of severe hypoglycemia per week (less than 50 Mg) in the past month; 3) Severe hypoglycemia unawareness with blood sugars <50 at least 3 times per week over the last month; 4) Nocturnal hypoglycemia (BG<50) refractory to insulin dose changes at least 3 times per week over the last month while asleep, or, 5) Recurrent hypoglycemia seizures (1 or more seizure in the past year)…”
I was just told that Medical Mutual will pay for it now. YEA. I hope to get my new supplies next week.
NEW REPLY: The recent study, published by a JDRF-supported team in the September New England Journal of Medicine, found HUGE improvements in A1c among randomized, well-trained “aggressive” adult T1 participants using CGMS versus a control group with the exact same quality and quantity of professional support and training, but denied use of CGMS as a tool after being assigned to the “control” group. The results were an absolute slam-dunk, nobody can ever again claim “it’s not proven to decrease A1c” for competent, knowledgable, and attentive adult T1 pts. (T1 adults in so-called “aggressive” treatment.) Because it DOES. Anyone who even makes such a statement, for patients of this type, demonstrates themselves to be utterly unqualified and incompetent by doing so-- and WE can feel free to threaten such persons with approaching their licensing Medical Boards, asking to assign remedial action for “practicing beyond the scope of his/her competence”. You can’t be aware of the DCCT and this study and NOT see that the devices created a SIGNIFICANT improvement in the pt’s long-term outlook for complications, unless you ARE totally unqualified to have an opinion in this area.
End of story. Ref: (Ref. NEJM 2008;359 “Continuous Glucose Monitoring and Intensive Treatment of Type 1 Diabetes.”)
Hey Anne, we can probably fix that pretty quickly. Their pulling these “Guidelines” out of their asses, and when you mention that your side in an upcoming Court case will have public safety OFFICIALS testifying about the “safety” of car and truck drivers at bG of 51mg/dL, or 55 mg/dL, as well as documentation of a careful, peer-reviewed STUDY conducted to find out just how badly human reaction times and quality fall apart as bG is forced downwards in a study context.- they’ll know of this study, and probably cave instantly.
They create “guidelines” which say 50 mg/dL isn’t an imminent danger to the pt., you threaten a civil suit, with generous punitive damages for having attempted to putting you at such serious and avoidable risks, merely to be more profitable by denying MEDICALLY NECESSARY and EFFECTIVE treatment.
Post a reply if you want me to review your letters, help draft up the next one.
BCBS of Minnesota covers with a 80/20 coverage. the cgm company calls for the guidelines and gets approval.
BCBS of Illinois covers also with a 80/20 coverage. the cgm company forwards a copy of the medical necessity to the insurance and insurance does a review and the approval is in no more than 30 days.
Hi Ken- I just joined this group, as I should be getting my first CGMS supplies today 
I’m in the Air Force, active duty. Talk about long, drawn-out processes…I fought for a year to stay in, and cleared that hurdle, only to be in another fight to get the USAF to let me “fly” the new “unmanned aerial vehicles” or UAVs. Key word there is unMANNED. I’m not even in the plane. It may quite literally take an act of congress to get them to acknowledge that sitting at a computer with a joystick is perfectly safe. Anyway, TriCare will pay for CGMS, but it will take some prodding, like all the rest. They’re a subsidiary of Humana, so if others are having problems, know that they WILL eventually cover it. Cheers!
This is in response to a post by Jan in October 2007 regarding Oxford. I think this message ended up in the wrong place.
Hi,
I realize you wrote this more than a year ago and things might have changed, but does Oxford (ours is going to be a Freedom EPO) require you to submit a letter yourself or does the endo submit it? We are switching as of 1/1 2009 to this plan from one that covered sensors, Minilink, etc. and I understand Oxford has a specific procedure. (I can’t get information from them because we don’t have our ID’s yet).
Thanks,
Arlene
Brian,
am also in the AF. Received my disapproval ltr last week. Can you share your CGM justification letter or other successful “prodding” techniques ?.
I have United Health Care (PPO), and they approved coverage for CGM (under durable medical equipment, 100% coverage after my deductable’s met!) with a doctor’s letter of neccessity plus 2 months of blood sugar results. MM actually did most of the paperwork for me so far as insurance co requirements.
You are in the military? I was under the understanding that the military will not allow type 1 diabetics at all. My DD wanted to join the military, but after talking to a few people, here and in person, that was nicked. Were you diagnosed after getting in? Or before? Just curious.