Thanks for all of your efforts to research and push for approval. I just bought a box of unexpired (12/20) G3s on E-Bay for $250. I am just finishing up my three expired boxes which I previously bought on E-Bay for $175. Only three of them did not make it to
14 days, including one that only lasted two days. Still saved a lot of money.
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Don.
Your comment is so appreciated.
Though there is much nay saying and that is fine. I will continue to try to make them/someone aware.
You never know who may read your plea/appeal and make a difference for more than my husband.
More people should appeal.
So far this discussion has been focused on getting access to the Guardian 3s, but to me that leaves open a couple of questions. One is that it truly sucks to be without a CGM, so Iâm wondering if thereâs any downside to going ahead and ordering a Dexcom (or Libre) system while the Guardians are making their way through the approval maze. I dunno from Medicare, so I donât know if that would lock you into just that brand of CGM, or would you still be free to switch to the Guardians if/when theyâre approved? I know for me on private employer-based insurance I was able to switch between brands at willâthe prescription just says âContinuous Glucose Monitor,â not any specific one. So I switched from Dexcom to Guardians when I went to the 670G, and switched back to Dexcom from Guardians 4-5 months later when I gave up on auto-mode and decided that my preference for the Dexcom outweighed any benefit I was getting from having an integrated pump-CGM system (almost none).
Which kinda leads to the second question/observation, which is that not everyone thrives on the 670 system. Some do, but plenty donât (YDMV), and the difference largely seems to have to do with how well your control was before auto-mode. People who are struggling to get their A1C down into the sixes tend to love it, people already doing that well and hoping for better, not so much. So I can totally get why you want to have access to the Guardiansâthey are what the pump is designed to useâbut itâs not the only option if you decide the HCL settings are too rigid, youâre not getting the results etc. You donât have to use the M-T CGM, though there are certainly trade-offs. BTW, Iâve recently upgraded to the Dexcom G6, and itâs so superior to the Guardians (and even the G5 for that matter) that I wouldnât go back to them for anything. I know G6 isnât through the approval process yet but word seems to be that itâs immanent.
In any case I would encourage you to look at other interim alternatives if thatâs a possibility for you, because being without a CGM of any kind until this whole Guardian issue gets ironed out is not a good solution.
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You canât change brands until the warranty is up and the warranty period for Medicare-provided items is generally longer than non-Medicare warranties.
I knew both those things were true for pumps, but youâre saying CGMs too? (Is there a warranty period for CGMs?)
I think (not sure) that the receiver is 3 years for Medicare patients, but donât quote me. I still not know yet if they will try to transition me to a G6 prior to the receiver warranty expirationâwe will see. But that is a different issue than asking Medicare to cover a different brand of similar equipment prior to warranty expiration.
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Does Medicare still require you to get the receiver? I thought they were ok now with running off the smartphone app. But before I wander any deeper into my ignorance of Medicare, the overall point I was trying to make was that the OP seems stuck on the concept that they need to have the Guardians, but as you and I both know you can certainly use a different, stand-alone system (doesnât have to be Dexcom) if you donât care about the closed-loop stuff. I guess part of what Iâm asking is, how much do they know about that stuff, is it really important to them, vs the disadvantages of not having a CGM at all for the duration of their appeal, outcome uncertain. If it means theyâre stuck with whatever alternative they choose for three years, that could be a problem or not, depending. For my part it wouldnât be a problem at all, given the superiority of the Dexcom and the problems I had with automode. Just seemed like someone should raise the question.
This is a very well thought out and valid point. From other members on this and other forums, the appeals process can take years. The OP is in the infancy of the appeals process. When it reaches a court room, it will get very expensive with court and attorney fees.
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I was just reading about this on dexcom website. Yes, receiver is required purchase, because that makes it the durable part, that requires supplies (transmitter, sensors). But also says phone is ok to use.
So I guess they could hang a three-year warranty restriction on the DME part and youâre committed for that amount of time. Probably Libre is the same, since thereâs a reader thingamabob or whatever. I still think itâs worth considering the alternatives, though, since until they authorize the Guardians or your appeal goes through, youâre stuck without a CGM at all unless you use something else. And it looks like the G6 approval is in the pipeline already, which is (for me anyway) a categorical improvement over anything else out there.
Currently 1 year for G5, but not sure if medicare forces a new receiver purchase, at eow.
Rollout of G6 is based on transmitter being end of warranty. Makes sense, but then MC may cover new DME G6 receiver, while G5 receiver still under warranty. Or new G6 receiver sent âfreeâ at initial transition order.
When I got my G5 (2 years ago) ,the receiver was required. Iâd expect nothing has changed as they have to have a DME item to base the replacement period upon.
I am happy that you were able to appeal, but that is not an option for us. My husband has had the Medtronics 670 loop system with guardian 3 sensors for many years. We recently went on Medicare and I did my due diligence and investigated all coverage details etc. I called Medtronics prior to making our decision as to what supplemental insurance as well as what Medicare program to chose. We chose to go with the original A & B and a medex bronze supplemental also a part D for prescription drugs.
My first frustration upon trying to order insulin was the lack of knowledge on how to bill insulin infused through pumps through part B. It took us going to 3 different pharmacies and 2 mail order pharmacies befor we found one that could properly bill us (part b then the supplemental). This is heartbreaking to think that the elderly have been treated this way, and my assumption is that most would not go the route we have to get the coverage they are entitled to and pay dearly for.
Our second frustration came, and we presently have not ordered yet, but need to soon, when we had to order sensors send were told that Medicare does not cover them. When I did my previous homework, I was told there was a financial aid program that could help us financially. When I went to apply for the financial aid and called Medtronics for the paperwork to apply, I was informed that because we were on a Medicare (government funded program) we were ineligible for financial aid. My question here then is why were we told it was available?
Outer third and last frustration came when we went to order the sensors and were told we had a form missing and until the form was signed and received, they could not fill the order. The for is called âABN or advanced beneficiary notice of noncoverageâ. This form comes to you with CGM sensors listed in the top box for $608.30 (this is a monthly charge! The form states that you can have Medicare billed if you choose option one, but you will pay the $608.30 out of pocket per month granting you the option to appeal when you receive a denial from Medicare. If you choose option 2, the form states that you can obtain the sensors, but do not want Medicare billed. What Medtronics will tell you in a phone cal, verbally, but this figure is in no place written on the for, that they will charge you $345 for the months supply!
The 3rd option is you choose not to have the sensors, that you understand Medicare cannot be billed , this is your choice and you cannot appeal medicare - (so I guess you live without this lifesaving device and die a slow deathâŚ)
So, 608.30 if you want to have Medicare billed, receive a denial and be able to appeal, or $345.00 (reduced monthly charge)with no Medicare billed, therefore no appeals process can take place. Without a denial, there is no appeal!
The OOP is so cost prohibitive that I am sure most people choose option 2, which is what we decided to do.
I do have lots of questions still the biggest one being, how does Medtronics get away with charging Medicare $608.30 and the consumer without billing Medicare $345?
We have spent so much time and energy trying to find a solution to these issues, it there is one out there, I would love to hear from you. Thank you
Prior to being transferred to a Medicare Advantage Plan two years ago. I had a UnitedHealthcare supplementary plan that paid 80% of the sensor cost
I would check with United Healthcare to see if they still offer such a medicare Supplementary Plan.
The original poster is @sally and may respond. I am not on MC, and donât use nedtronic sensors.
Don1942
I am afraid that if Medicare does not cover The sensors that no supplemental plan will cover. The way Medicare works, at least my understanding is, they need to pay before a supplemental kick in. If Medicare denies the supplemental will also deny
Lori I know about Medicare and the Sensors but have to read what you wrote more carefully. I think I addressed this in a separate topic post and will look for it. If not I will reply later after I read again more carefully what you wrote to be sure I understand.
I know this is terribly frustrating.
I have been out all day so am a bit tired. Back very soon.
Lori,
Please ask me any questions you have.
Not sure if this is what you are looking for. I posted this a few weeks ago under another forum topic.
Again I hope this at least partially gives you some background on my experience with Medicare and Medtronic.
I will tell you the outrageous behavior of Medicare and Medtronic is ethically criminalistic.
I think I made up that phraseâ:smirk:
Lori again here is my entire post previously published in this forum.
I meant this to be a private message to Steve but here it is. Hopefully it will help others.
This is my experience, my thoughts and my opinions.
I am posting this to be helpful.
Hi Steve I am hoping Ken will reply to my original message to him so I can cut and paste what I wrote to him and get to you and another guy about Medicare and appeals. I canât get to the message I sent him for some reason.
Here is what I know.
Stock up on your sensors right now with your insurance plan.
I hear they are now asking people if they are going to be on Medicare when you call once you are on Medicare, at Medtronic, and then they tell you that you have to pay 354. Out of pocket per box which is not really fair because there are some secondary insurance companies that will pay if you are on Medicare so they should submit to Medicare and if they deny go to your secondary but remember these people are out of call centers and do what they are told and will not most of the time get you a supervisor to speak to. The last one I talked to on the phone was especially resistant to listening to me about the whole case by case deal. See next paragraph. If you pay the 345 out of pocket I donât see how you can get a Medicare denial because Medtronic has never submitted to Medicare. See what I mean?
This is why I called. Yes I did win my appeal for the sensors but the appeals are case by case. You would think that since the boxes were approved and my husband will be getting the same sensors that Medicare approved this time around. Nope. The call center person I called at Medtronic would have laughed full on in my face if she could have.
Steve, here is the good news.
If we are lucky and this goes thru then Medicare may be covering the G3 Sensors and you will be fine. And I hope this happens.
Also they are suppose to be coming out with a 780 insulin pump at some pt. And if you are still under warranty with yours which I bet you are you can pay a fee and update your 670 pump.
https://myglu.org/articles/medtronic-launches-in-home-trial-of-780g-clinical-trial-of-new-cgm-sensor
Do you extend your sensors?
Medicare and secondary insurance as I call it costs us about 1400 dollars a month and as you know with diabetes there could be other multiple medical issues and I have Rheumatoid Arthritis. Our plan is good and we have not paid a dime out of pocket this year at all and believe me we have loads of doctors appointments. Well enough about me.
Anyway I will be damned if I will pay 345. Out of pocket for sensors and so we appealed and won.I will send you that info also soon. We got close to 1000.00 covered by Medicare with our appeal.
People on the forum told me to not even try to appeal but I didnât listen. Itâs been a fun 38 years for my husband. Ha ha!!! Because the process is there I am willing to go thru it and I hope upon hope it will help someone else. Foolish in this day and age but I try nonetheless because it is my right.
I hope this info helps you.
I am a librarian by trade so try to give reliable info.
If you have any other questions let me know.
Though I have proofed this please excuse any incorrect spelling and grammar.
Thank you Sally. After reading your email am I to understand that you approached your supplemental with the info that Medtronics will not bill Medicare so you cannot get a denial therefore you proceeded to appeal to supplemental to cover costs incurred?
We cannot load up on sensors because both of us are on Medicare with a BC/BS Medex Bronze supplemental insurance; we purchased the best plan thinking we would have great coverage.
Also I did speak with Medicare multiple times and poised the question of coverage and was assured that part B would cover the sensors. This is even in the Medicare manual of coverages. I was also told that it was not name specific sensors, now we are here with Medtronics sensors, no coverage, only OOP. We have not put in our first order yet, but had to sign a form (if we wanted the OOP pricing) stating that we would choose not to bill Medicare in order to be billed at the lower price. We could have chosen option 1 (agree to have Medicare billed, receive a denial and pay the $608.30), but feel that option would still be out of pocket; therefore we opted for the option 2.
I thank you for your blog and all the info and look forward to hearing from you.
Lori
Hi Lori. Let me think about your question a bit more and get back to you. Sally