My insurance won't cover that

1

OK, y’all, a call to vent! I see a pattern in our lives – one of bean counters getting between us and the medical care we need. No, you don’t have to name names if you don’t want to, but I’m interested in a compendium of what you or your doctor would LIKE to try in the quest to get your diabetes under excellent control, but is being withheld, blocked or limited due to the rules or limitations of your HMO or insurance plan. Fire away! I think we all need to see and acknowledge how we are being hemmed in by non-medical decision makers. Do you have any road-blocks? I know you do.

Here’s my list:

1) Gastric bypass surgery – my HMO has some group plans that cover it, but NONE of their individual plans will cover it; several of my doctors (sleep specialists, endocrinologists, internists) have recommended that I have this diabetes-crushing procedure. Gastric bypass is rapidly becoming the standard of care for people with multiple obesity-related diseases, a high BMI and a history of failing at serious efforts at weight loss (I’lve lost and gained over 100-lbs. four times as an adult, twice in medically supervised programs) – but it’s not covered. Even if I raised money for the procedure, none of the post-surgery care or (possible) complications would be covered, either.

2) Levemir – everyone recommends that this would solve some of my problems with Lantus, but it’s not in my HMO’s formulary;

3) CGM – T2’s like me who are having a hard time juggling multiple daily injections of insulin (going hyper and going seriously hypo at seemingly random times) do well with CGM. It helps them solve problems and improve their A1C’s over time if they’re willing to work at it, but my HMO plan won’t cover it;

4) Pump – Having a pump would help tremendously with my fluctuations in basal, bolusing for an erratic eating schedule and need to have very different insulin inputs depending on my exercise schedule. I think I could come a lot closer to flat-lining if I had a little time and help adjusting my dose via a pump. However, my HMO plan won’t cover it.

5) Counseling – I could seriously use some help with handling the severe stresses in my life (e.g. PTSD after an assault last year), my food/eating issues and coping with my health problems (e.g. diabetes-related chronic depression), but my HMO will only cover 12 visits per year with a counselor, and I have to jump through a series of hoops to get those approved. After those visits are used up? I’m on my own, no matter how distressed or depressed I am.

6) Diabetes support group – the HMO doesn’t have one and participation in one outside of the HMO (e.g. one lead by a CDE or doctor)? Not covered.

7) Nutritionist to help with low-carb diet – the HMO will only cover me to see their nutritionists, and NONE of them offer any help or advice regarding a low-carb diet. In fact, if I go to see one I can count on them telling me “eat more carbs, eat more carbs”, even when my A1C was 10.7.

OK, I’ll probably think of something else. Now it’s your turn…

2

My experience was to lobby the insurance company in particular the cgm with data showing the recommendations of the Association of Endrocronologists and also court orders forcing BCBS to pay for theCGM. It took a month and I was fortunate to have a pretty good employer advocate who was willing to buck the Medicare guidelines which many insurance companies adopt.

When I was buying out of pocket because of super high deductible, i found that buying drugs ibn Canada helped; In another post on complaints about Craigslist, I did see a post for a free Deltec Cozmo - I almost went for it - I used the Deltec for 3 years before trading in on an Animus and in many regards liked more than the Cozmo, Also Dexcom does have a program for people without insurance that reduces the costs, but I would start aletter writing campaign to the insurance company.

3

We shouldn’t have to.

4

Some of those programs for “uninsured” only apply if you have no insurance. If you have insurance, but the insurance company won’t cover it, then it wouldn’t apply to you. I am not sure if that is the policy of Dexcom or not.

5

I actually have had really good luck with my insurance company. I was able to get a CGMS thru appeal. My problem wasn’t with my insurance company, but with supply companies and my doctor’s office. When I decided to try & get a CGMS, I knew my insurance would deny it but I felt I had good cause to appeal. I have a Medicare Advantage plan and supply companies would not even try to get approval – they said it was not covered and would not even try. The insurance company had to deny it before I could appeal it. It was actually my insurance company that helped me get around the supply company and told me to have my doctor try to get the authorization.

Apparently the nurse at my doctor’s office did not want to do that and she lied to me and told me that the insurance denied it – seemed funny that I did not get a notice and they did not get one either. I called my insurance to find out that they never contacted my insurance company. I then started calling the doctor’s office every week to get it done. After I passed out & gave myself a black eye & bloody nose, I made an appointment to talk to the doctor. The nurse decided to call my insurance that day to find out what needed done – I had been telling her for 2 months! The insurance denied it, I appealed and won.

I now have a different doctor and they seem no better with paperwork than the old office. It is always fun to call that you need insulin called in & they don’t do it. Not that I really need it or anything! I want to change supply companies because the one I have been using raises their price for the sensors every time I order them. Because it is not something my insurance company has a contract with anyone for, they pay what was billed. The last ones were $775 a box and supposedly, Dexcom sells them for $325. I know American Diabetes Wholesale has them for $334 so I can’t justify my insurance paying more than double for them.

I want to change supply companies because I found one with a list price of $550 – that is more than what ADW charges but it is still $200 cheaper. I know it is pointless to try the supply company first without an approval code but getting my doctor to do it is going to be very frustrating!

6

yes I had insurance and at the time it was not covered (it since has been added) but Dexcom still offered a cash discount

7

Jean,

I know that we should not have to but we are each responsible for our own outcomes. We can be persistent and play the squeeky wheel and hopefully make some progress or we can roll over and play dead. Things won’t change until we make them change.

Good Luck - I wish you well and wish u did not have to argue for what you need!

8

If it’s any consolation, no nutritionist is going to help you with a low carb diet. Eat more carbs is their mantra. Everyone I know doing low carb did it on their own. Not really much education needed in this area that you can’t teach yourself.

The support groups I’ve seen don’t charge, but maybe that’s atypical.

Anyone with a chronic disease should have access to counseling.

I’d like to see CGMs be offered on a rental basis through docs. Loaners for a month to help learn patterns without the ongoing expense.

9

I suppose I’m unusual/lucky, but the nutritionist at my endo’s office was perfectly ok with me doing low carb. Her only concern was that I get all the nutrients I need. We went over the sorts of things I usually eat, and she even gave me some suggestions.

10

I’ve delt with the problam of Insurance not covering mANY things and more or less learned how to do thingsthat help me out. I’ve delt with Type 1 (I know it in’t TYpe 2) since 73 and I’ve found out that your body can tell you more than all this other stuff. Just saying…

11

The rental CGM is a really good idea. I think that doctor/ patient communication is a huge problem (possibly because I suck at logging things? But I’m pretty blabby and can talk my way around all sorts of stuff…) for people w/ diabetes. The data in the pump/ CGM setup is a huge bonus for me. I don’t recally it really being mentioned a lot during the “sales” portion of my pre-pump/ CGM discussions w/ docs/ MM people but it’s really be helpful for me and, I’d hope, the docs to have better data!

12

Yar, I have the opposite problem with my OneTouch. My doctors looks at the downloaded data – which OneTouch files into neat little columns which are worse than meaningless – and think they understand what’s going on – but how can they? My sleep schedule is so erratic that my “10 hour fasting, upon arising” number might be logged at any time between 3 a.m. and 3 p.m. It mixes my fasting post-walk numbers with my post-breakfast numbers on the days I walk in the morning. It files random readings (hours before my next meal) mixed in with my pre-prandials readings (just before eating.) They’d be better off just throwing all of my numbers into a bucket and drawing them out at random. It simply won’t let me note what is really going on (when I go to sleep, when I get up, when I go for my long walks, when I take four-hour naps and completely miss a meal, which reading is one hour post-prandial vs two hour post-prandial, etc.) How can anyone get anything useful out of that unless they have psychic powers?

13

I agree w/ that. I’m in the midst of the same deal about test strips. Letter saying “go to hell biyotch. You get 200 test strips/ month b/c the FDA says so” so then I call "oh, your doctor has to fax a letter [I have a copy, it is funny b/c it’s so stupid that the doctor has to waste their time w/ this…] to this other fax number"and then they decide what they will do.

14

Yeah, they’re happy to pay to have your precious feet cut off, but they won’t pay for piddling little test strips to prevent it. How sick is that?

15

sort of eerily, I got their letter the day after I signed up for the Chicago Marathon…GRRR*

16

Hugs, Doris.

17

Need to add crystal ball to the list. When I log, which I’m terrible about doing, I write it down. Found this the easiest & fastest way to see what’s going on.

18

I write every single thing down – on a log I got from my HMO – but the doctors who WORK for my HMO won’t look at my logs. They look at the data from OneTouch. It’s maddening. I even asked my newest doctor if there was a preferred way he’d like me to write up my log (a format he prefers) and he said no and shrugged, but he barely glanced at my meticulous records.

It’s enough to make me want to scream bloody murder and start breaking things just to get their darn attention. HELLO? YOU’RE BEING PAID THOUSANDS OF DOLLARS EVERY YEAR TO HELP ME. I might as well just put the money in a pit and set it on fire.

19

Jean,



Do you have the software on your computer, or do they download it at the office? IF you have it on your computer, somewhere within the settings, there may be areas to set the time frame, for yourself. I have it on my software (Co-Pilot, for Freestyle and Navigator), and I can set the time frame to what I want.



Now, it could be because I’m T1, but I only print off the Statistics Report, and the Glucose Line graphs. Those two reports tell my doc anything he wants to know. So…that may be better for your doctor to see, versus log files? Food for thought.

I do keep written log files though.


Trisha

20

No, they download it at the office.