This was a new one for me that I found interesting. Medicare refused to pay for test strips because the person had a DexCom CGMS.
I have seen a hint of this problem to come a couple of times in the last year but this is the first flat out refusal I’ve seen with the reason for denying them being “has DexCom sensor.”
So DexCom G6 has been indicated to be use without having to “calibrate.” (Personally, I’m pretty sure that is why Medicare approved DexCom but refuses to approve Medtronic. They don’t want to pay for a sensor and strips.)
My personal theory on the matter is this:
DexCom was supposed to release the G6 to Medicare patients in March but it has been delayed. My guess is that Medicare has been gearing up to deny test strips to CGMS users in anticipation of them receiving the G6 (who knows that may be giving Medicare too much credit and Medicare may think that ALL DexCom CGMS are indicated for use without calibration").
(Why Medicare would assume that just because the G6 would become available in March would mean that automatically every single one of their patients would be on the G6, I’m not sure.)
I wrote a letter to our jurisdiction medical director for Medicare DME and pointed out that the G6 has been delayed and that the G5 still, technically, requires calibration for use so test strips are still a necessity. I sent that yesterday and I’m still waiting to hear.
I’m curious if anyone else has run into this yet?
Slightly off topic but another interesting thought:
For Medicare to continue cover pump supplies, a person has to be testing their blood sugars four times a day. So what is Medicare going to do when they (Medicare) won’t cover test strips because a patient is using a sensor and doesn’t “need” test strips but they (Medicare) still require four times a day testing to use the insulin pump.
In a perfect word, Medicare would realize that with the CGMS that doesn’t need calibration there should be no reason why a person has to physically check their blood sugars four times a day as an insulin pump use requirement but, knowing Medicare, somebody is going miss that memo…
I am on Medicare and just received my Monthly (March 2019) set of supplies from Dexcom including 5 sensors and the 150 test strips I requested a few days ago. Nothing any different from any other month in the past. My orders are placed and come directly from Dexcom in California.
Hmmm…This happened when trying to obtain the strips from the local pharmacy. I wonder if that is the difference. I have seen here that there were some Medicare people having difficulty obtaining test strips this year from local pharmacies when they were on a CGMS. Someone said that they were told that it had to go through the DME supplier. I had not come across that yet but maybe this is more of that issue??
As of late last year, Medicare declared that Dexcom-direct users get ALL their strips from Dexcom. Works for me and my wife–we simply called our doctor’s office and had them fax a new Rx directly to Dexcom. Works like a charm. I can’t for the life of me figure out why some many people have some many problems along these lines. It’s not like I’m special, or smarter. I just make calls, find out what’s going on, and play the game.
The problem is the libre can at times be very unreliable - it has been good for my wife lately, but you never know.
Medicare will pay more in the long run as folks will end up in the ER for sure.
The problem is I don’t know how to appeal it because it will not even gets to the point of being refused - the pharmacy will not do it so there is not denial - I am just not in the mood to even call them. How can you appeal something that has not been denied?
I think the issue has never been with those of us that get our monthly supplies directly delivered to our home or business in 3 days by FedEx. The problem always appears to be with patients getting their supplies through 3rd parties, especially pharmacies. If you carefully comb through the last Dexcom conference call, they mentioned that they are working more partnerships with third parties to alleviate the stress on their distribution facilities. In some states, my understanding is that they no longer offer Dexcom direct service. So hopefully long term this will all be sorted out because when I read the medicare rules, they stated that a patient must receive a full month supply including everything they need such as sensors, strips, lancets and control solution.
The pharmacy should be willing to run it. They can’t predict with absolute certainty that it is going to be denied if they DON’T run it.
See if you can have the pharmacy run it if or a lesser supply (say 25 strips). Then, if it is denied, purchase the 25 strips and then fight with Medicare to get reimbursed. You have realize that 1) you MAY lose and Medicare won’t reimburse you for the 25 strips and 2) I don’t know if it fixes it long term for you or not. I’ve never known anyone did things that way (mainly because usually the item that you are trying to find Medicare on is too expensive to take the chance that they won’t reimburse).
Medicare is a tricky beast. It is EXTREMELY black and white. They don’t leave people much space to be human or “imperfect”. Sometimes I’m left feeling that Medicare treats diabetics like every single person is a carbon copy of the next and it is exactly the same for every single person and diabetes is so far from that.
They do run it - there is a maggot outfit between them and medicare - I am told they all have these outfits that submit it to medicare - It never goes directly to medicare
They have to call to get an override to get insulin - they call and talk to a machine - hours later the override gets done and the insulin can be filled.
So, I have to call a day ahead to even get insulin - they want to make sure I am not getting strips
I will add this pharmacy has bent over backwards to help and has done a most excellent job (even redoing paperwork and keeping it on file) without one word of complaint over the last few years
I have seen them personally submit it and get rejected and then call to try to fix it.
Maybe all the complaints for each 3rd party supplier should have their own threads instead of one ■■■■■-fest against Dexcom & Medicare? Just a thought.
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The pharmacist printed the rejection for me - When I googled the name it stated they were in the business of making sure folks did not get unnecessary meds - not the exact words, but that’s what it meant
You are right, I have never seen the control solution in the monthly re-order form. Medicare says everything needed which is why Dexcom supplies Meter, Test strips, battery, transmitter, receiver, control solution, sensors, transmitter, manual etc. in their initial package.
It would be interesting to ask for additional control solution based on it being dated or new battery if and when needed. There possibly appears to be a gap between what Medicare requires and Dexcom delivers monthly, but it may also be that Dexcom will willingly send out more control solution or a battery if requested. I don’t use control solution so have never tried, and my time is more profitably spent ordering extra batteries through Amazon with prime delivery than spending lots of time on phone with Dexcom. This is also probably not the best time to put additional stress on their systems.
I wonder if you “all” know that Contour Next batteries are provided FREE, for the asking, directly from the manufacturer. I’ve received batteries from them at least once.
No, I did not know that, thanks, but for me it is still far more profitable time wise to buy a bunch of them I can use in various devices for less than $1 a piece on Amazon prime with free delivery.
I buy them from amazon as well, but like I said, I’ve gotten free one from Bayer. It’s not like I’m a $200/hr attorney. I figure if you have time to post on forums, you have time to get free batteries via a phone call…
I used to get my Contour Next test strips from Walgreens to calibrate my Dexcom G5 which came from Byram Healthcare. Byram couldn’t supply the strips because I lived in a “competitive bidding” area. This year Walgreens called and said I needed to get the strips from the same place as supplied the Dexcom. I called Medicare and after much hemming and hawing and being put on hold for a period of time I was told yes, it should be part of a package order with the Dexcom supplies from the DME supplier. (After further research I learned that Medicare has suspended the competitive bidding program). After a lengthy call to Byram, the rep. I spoke with seemed completely unsure about anything. Another call to Medicare and after a lengthy discussion with the rep. I was connected with a supervisor who told me NO, in no uncertain terms, would Medicare pay for my test strips if they were paying for a CGM. Anyway, after several phone calls and much time on hold and explaining to Byram that the competitive bidding program no longer was in effect, they finally sent me a new Agamatrix meter and test strips. Contour Next was not an option. Time will tell if Medicare will pay or if I am billed.
