Continuing the discussion from How does Medicare coverage of CGM affect you?:
Richard, I am also on Medicare and intend to use Dexcom CGM. I have been reading up on the subject of Medicare denial of CGM. I have looked for text similar to yours. Here is what I found:
"… will cover 72-hour continuous glucose monitoring for patients with labile blood sugars and the need for intensive short-term monitoring for improving blood glucose control." Is this the wording in your denial? Can you scan the document or take a picture using your cell phone and attach it to your reply.
There has been a major win for a TYPE 1 Patient recently in a Court case WHITCOMB v. BURWELL on May 26,2015 in United States District Court, Wisconsin. From what I have read, the support for Medicare’s denial is specific in an earlier article A47238 which has been superseded by LCD (Local Coverage Determination) 27371, which does not contain any reference of CGM. So the Medicare denial is in error.
From a review, “the Secretary, through the Medicare Appeals Council, erred when it concluded that A47238 is incorporated into LCD L27231. Nothing in LCD L27231 attempts to incorporate A47238”… which unambiguously states that continuous glucose monitors are considered precautionary and not covered by Medicare. [Decision page 8] “If the reference to the continuous glucose monitors contained in the Article had been included in the LCD, the outcome of this case likely would be different. But the fact that the LCD is silent as to whether continuous glucose monitors are covered is not a matter the court can overlook.”
see review https://disqus.com/by/disqus_YOfNRxfbdg/
So, my guess is that Insurance Company has found language in existing Articles to deny coverage.
I know in my case my insurance will deny coverage for my CGM. I am getting ready for the long battle. The Diabetic person in the above case fought his way through 5 levels of decisions. The first two levels were denials, the next overturned the denials and approved, the next overturned the previous level and denied and finally District Court found for the Plaintiff, the patient.