About a year ago, I contact DexCom to try to get a 7+. It was denied. I appealed that denial. It was denied. I appealed that denial. It was denied again. I appealed that denial. Yesterday, I got a big packet telling me that it was once again denied. None of the denials have been based much on fact. The second used information from studies done in 2000 and 2002. Each denial seems to be confused about whether I am type 1 or type 2 - the fact that I was 8 when diagnosed and hospitalized with BS of 1900 does not seem to convince them I’m type 1. (Grrrr. Evil insurance companies.)
Anyway, the most recent denial was done by a physician who is “a Fellow of the American College of Physicians, Diplomate of the American Board of Internal Medicine and board certified in Endocrinology and Metabolism treating adult, adolescent, and pediatric patients. This reviewer is a Professor of Medicine at a college of Medicine…” Etc. So, the reviewer should know something about CGMs and diabetes. However, they told me it was not medically necessary.
I’ve posted on Tu quite a bit, and I massively overinject myself with insulin. People keep telling me it will kill me. I’ve been hospitalized about 30 times in the past year, and passed out from lows several hundred time (in the last year). The doctor’s denial said that if I would just follow doctor’s instructions, then I wouldn’t have lows, and I would be fine. However, I don’t do that and just telling me to be good is not going to fix my problems.
Anyway, this post is mostly done so I can complain about how evil insurance companies are. (I MEAN, COME THE F%CK ON! IF ANY DIABETIC NEEDS A CGM, I DO! I OWE ABOUT $10,000 TO HOSPITALS BECAUSE OF REPEATED LOW BLOOD SUGARS. EVERY DOCTOR I’VE SEEN TELLS ME I’M GOING TO KILL MYSELF FROM LOWS. BUT MY F’ING INSURANCE COMPANY TELLS ME THAT I DON’T QUALIFY FOR A CGM. Ahem, sorry, I just had to get that off my chest.) But I also wanted to know if anyone had any experience in successfully appealing CGM denials and what worked.
Thanks.
Anna -
Dont I KNOW about frustrating Insurance companies! I had to jump through hoops for them to cover my f’'n STRIPS! When I wanted to first go on the Dexcom, I had to have my endo call Dex and speak to them about the necessity, then he wrote to my “insurance” company (Anthem BC/BS) and explain the necessity of the CGM. They wrote back to me and told me they needed 3 months of bg readings along with a form my doc would have to fill out. I just created a “3 month” record on an excel spreadsheet, (my doc told me to just include bg readings of less than 50 at least ONCE a week). After all that crap, they FINALLY agreed and covered the Dex. About a week later the idiots at Anthem called me and told me I was a candidate for their “diabetes assistance program”, where they had a full time RN on staff to answer all my questions about my condition and what could be done to better care for it. I thtought, “wow, this is a JOKE. This is the insurance company that I am always at odds with over the number of test strips I need or if it is better to have a CGM” Needless to say, I told them to &^%$# off.
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Yes! My insurance company has a “diabetes assistance program” too. It is so incredibly useless, but, in my denial, they say, “She’s not using our diabetes assistance program, so obviously she doesn’t care.” I’m sorry, I don’t want to talk on the phone once a week to some lady who tells me to test my blood sugars.
hmmmf, that’s a good point that I hadnt thought of! Maybe they ARE writing me off becuase I dont accept their “services”…although I did actually starta an argument with one of the “experts” who had called about a month ago offering the service, saying “Really? You think you know more than Me? A person who has lived with this condition for 30 years? And I KNOW as does any knowledgeable MD that the more times one tests the better off they will ultimately be! And you know what? That will actually end up SAVING YOU IDIOTS MONEY!!!” needless to say, they were not interested in speaking to me anymore. I havent heard back since! I hope this doesnt spell trouble in the future!?!
I agree that insurance companies are filled with a bunch of jerks but why are you overinjecting? Is it that your insulin to carb ratios are incorrect? I know for myself a lot of times I think I will eat a certain amount and then end up eating half as much so I have taken too much insulin. But I found the best way around that is to take half my insulin at the beginning of a meal and the other half if needed at the end.
I’ve had several instances of success in this area … it’s been a hobby of mine, since 2006. (Against several insurance companies, for several different people, in several different States.)
But from what you have said here, I would advise against attempting to appeal. (Or threaten to sue. Or threaten to request an investigation of the MD’s competence. I win by doing all 3, together, in the same letter. A second letter has never been needed.) You seem perfectly aware of a MAJOR problem in your treatment already: You keep doing “massive” over-injections and cause problems, and that MD seems correct from a Diabetes perspective – you would do better by following instructions.
Since he was right, his denial works. You can’t demonstrate that it’s really “necessary” until you’ve done everything you can with the cheaper traditional treatments, and proved them to be insufficient. So, before you go and try another request for coverage of CGMS as a “medical necessity”, I think that you should make a first-class attempt to use the standard tool set first: Honest and accurate logging of insulin, diet, and bG readings. You need to be compliant with your carb ratios, diet plans, and basal dose adjustment strategies first – then, if you still have troubles, demand CGMS.
** BUT: **
None of that becomes possible until you can stop this habit of shooting in “way too much”, way too often. Let me venture a guess: Maybe it’s not just a “mistake” anymore. Rather, it’s grown into a syndrome of self-injury. I’ve read that many kinds of self injury (e.g., “cutting”) often occur together with eating disorders. Are you doing the insulin overdoses in connection with meals or snacks gone overboard? You might be provoking a later Hypo for the purpose of getting the guilt of the “bad, bad!” eating behavior out of your head – by creating something bigger, scarier, with real risks.
If the reasons behind this pattern of “over-shooting” is even remotely like my guess, then I’d get to work on un-doing the compulsion first. I’d get in to see a mental health professional, ASAP. (NOT my diabetes people.) But YMMV, and I’m only making wild guesses about your situation.
I’m not exactly ‘fond’ of Dexcom at the moment either…however…it seems to boil down to playing the game by their rules and jumping through hoops if we want to use their product. My situation is a little different than yours but I still don’t understand WHY I have to do the things they are requiring of me. I’ve already been approved once (last year) and I’ve been using the Dexcom since 9-2-09. Now they are making me go through the application process all over again. I have to provide evidence of a c-peptide test, evidence of completing a comprehensive diabetic education class and 3 months worth of blood sugar readings + my Endocrinologist has to fill out a 30 question paper on my compliance as his patient. And this is AFTER I’ve already gone through the application process once and been approved.
Still trying to decide if it is worth it or not, because if I’m “approved” this time it will be for the privilege of just being able to buy the sensors out of pocket. My insurance is Medicare which does not cover these ‘unnecessary’ things. So talk about angry …
Maybe you could try and get the tests they require and jumping through their hoops, it might work for you. Like it or not, sometimes we have to play the game by other people’s rules even when it makes no sense at all.
hear hear Mayumi! Let’s just look at this entire stupid thing as a game! PLAY ON! I WILL WIN!!! I am almost 50 years old and have beaten these idiots for 30 years! I’ can take anything they can dish out!
Every time our insurance pulls a shenanigan, we just send in a form our state insurance commissioner provides to the state and i “temporarily” gets a red-carpet treatment…
YEAH Anonymous D! You have given me a “next time” move!
Sadly, I work for the state, so my insurance is the state insurance. Since our state insurance commissioner is going to tell us he has the same insurance, he’s not going to disagree with them.
Accept their assistance and then tell them you must confirm their recommendations with your endo. Also, most of the “assistance nurses” are not CDE’s. Therefore, without the CDE credential question their knowledge. Does the assistance program link you 1:1 with a nurse or is it a pool of nurses? Find out about the nurse - RN or LPN, level of education, experience, credentials, etc. Get more players on your team.
Managing DM is a team task. The more people you have watching for new and better ways to work things out the better.
Anna,
Start playing hard ball.
- Work with your local library (public, community college, or best a medical school) to request newer research articles showing the improvements achieved with CGMs.
- See if a local nursing school requires students to perform community service as a part of their nursing education. If so, get a couple of nursing students to chase the information and also become advocates for people like us - need a CGM.
- Be meticulous in your data diary. Start with a food diary adding BG and insulin. Get your IC and sensitivity ratios fine tuned. Document calories, fats, protein, fiber as well as CHO. The TAG group has something going there.
- See if your endo will contact Dexcom for a loaner week - one sensor, etc and the local Dexcom rep and you can collect data from the loaner to prove a case.
- As far as the appeals go. Disect the rejection and prepare a rebuttal with the help of your endo, the endo’s CDE, the local Dexcom representative, a nurse friend, etc. Fight fire with fire.
- Most of all - take care of yourself. If you take good care of yourself and be your “health care team leader”.
Let me know what you think. Sometimes I get TOO Preachy.
Jay
I like the idea. Unfortunately, the nearest endo is 500 miles away by plane. And my insurance won’t cover visits to the CDE (they don’t cover diabetes education); I did see her a month ago, anyway, and she doesn’t really like the idea of CGMs, so she wouldn’t do anything to help me. I did get a loaner CGM for 3 days a year ago; it showed that I was completely passed out (below 40) each night I had it. That was informative, I guess, but my insurance company just told me to take less insulin. I keep a very meticulous diary, with carbs, BG, and insulin. Unfortunately, I have a big anxiety problem with high blood sugars, so I give myself way too much insulin. I know this; I’ve been in therapy and on drugs for it for years, but it doesn’t improve. People just tell me to stop giving myself so much insulin, but that doesn’t really help. Anyway, that was what my insurance company told me too - they said I didn’t need a CGM, because it was my own fault I was getting low so much. Which I agree on, but, goddamnit, that doesn’t mean I don’t need a CGM to let me know when I’m passing out. (I passed out 4 times this weekend, and the paramedics came twice.) Dexcom has also told me they can no longer help me, because too many appeals have been rejected. (They also told me to give myself less insulin.)
Anyway, basically, there aren’t any medical people around who can help. And my insurance company is notorious for being anti-diabetes. I am debating whether to bother filing an appeal to the insurance board of trustees. If they reject me, though, then that’s my last choice. But, since the reason I need a CGM is because I take too much insulin, I’m sure they’ll reject my claim for a CGM, saying that I wouldn’t need it if I just followed doctor’s advice. (Which is what makes me so frustrated; I know a CGM will not fix my problem of overinjecting, but it will at least alert me, so I won’t get fired from another job or kicked out of another apartment because I passed out again. I mean, yes, it’s my f’ing fault I overinject, but, no matter how hard I try to stop myself from doing it, I still give myself too much insulin sometimes. And then I sometimes pass out. Whether it’s my fault or not, a CGM WOULD help.)
I got denied many times then for some unknown reason in June 2009 my insurance (BCBS of MA) decided that hum maybe it would be helpful if we paid for this. I was known on a first name basis with the paramedics, local er and the er of where my endo was and the diabetic floor at the hospital my endo was at. Not something I was proud of. But since the cgm, I had not had one episode where I had to go to the er or 911 called. We just used glucagon once and that was cause I was sick and I bolused but then would not stop throwing up and the endo gave instructions to use glucagon for the insulin given so I wouldnt go low. Good Luck, and I hope you get approved soon.