I was just informed the AMA changed Sensors to Experimental. Before I would pay a durable medical deductable and they would cover it. Now after Medtronic submitted a claim I got a call that my crappy insurance, Coventry/First Health will not cover it. The claim specialist told me that it affected many diabetics. Why did this happen? What kind of moron at the AMA did this? Apparently all I have to do is prove I need them. My Dr. has already written a note saying I need it. Now they want medical records proving I need it. Anybody know the email address of the head of Diabetes at Medtronic?
In addition, is it a coincidence that I was slightly pressured by a sales agent at medtronic to purchase 2 extra boxes of sensors right before this happenned? They had told me that my insurance would cover it. Maybe this was a last ditch effort becuase they already knew of the policy change at the AMA. I am thinking that some sales manager caught wind of a change and tried this out. It worked on me.
Thats not right!!! Its just not right!!!
If your insurance won’t cover it after the Medtronics rep assured you it would, send the sensors back. It is not in Medtronics interest to mislead customers about insurance coverage and it is definitely in its interest to have its product covered. Typically, Medtronics and other companies will lead the inquiry into coverage for you and then let you know a) covered or not and b) your out of pocket cost if you elect to get the sensors.
I don’t know what influence the AMA has over insurance coverage decisions, but if it has any, this is a step backwards given that many companies were beginning to extend coverage.
As for what evidence the insurer might need, in my experience they want to see a 30 day blood sugar log with four to five lows. They seem to view the ‘medical necessity’ as hinging on preventing lows, rather than avoiding highs.
Terry
i had a similar thing happen with my pump.
the lady told me "oh yeah, they will cover the pump AND the CGMS if you would like…blah blah blah"
so i ordered the pump and faxed all the papers necessary.
and NOW she tells me i might have to wait 6 months WTF!
grrr…insurance.
I think the only reason Medtronic would do this is if they believed I would pay for it after I found out that the insurance would not cover it. I was assured coverage.
Apparently the AMA has significant influence over the insurers or it is a lie by Coventry/First Health.
If I had refused the extra 2 boxes of sensors the rep had assured me would be covered I bet I would not of heard a thing about it.
So it seems that Medtronic is on the line this time. I let Bill Hawkins know about his companies sales practices.
I wonder if CNBC would also like to know?
I will send the 30 days of blood sugar reading from the sensor and the latest A1C get them to pay for it, hopefully.
This is the first time Medtronic has screwed me. It may also be the last time.
Highs are just as bad as lows so they need to wake up and get their heads out of their butts and state any extreme fluctuation in blood sugar levels at the very least (this is why im not on a CGMS- I swing high instead of low because I fear lows)
Playing Devil’s Advocate here: I would consider CGM “experimental” in that it cannot completely replace fingerpricks and that it is said to have delays in determining steep curves and the magnitude of changes. This does not mean that the therapy is not useful, and potentially life-saving! But then the goal of the insurance bean counters is to get as much of your money as possible while providing the minimum level of coverage needed to do so.
I agree… I think so many insurance companies are waffling on coverage because of misunderstandings about how the system works - plus I think there have been a LOT of patients who pull the “but I won’t use as many test strips and it will SAVE money long-term” when evidence proves that just isn’t that case most of the time… CGMS is great for showing trends, but it can’t replace fingersticks and it really seems that in actual practice, people test MORE while on a CGMS - I think that in some cases seeing what it thinks your BG is doing all the time can make you more uncertain about things than if you just didn’t know at all.
I agree. The nice thing is that it is fairly responsive when you are active since it is measuring off of your interstitial fluid. It does not replacing the pricking of the fingers. What is so helpful is that you can manage tightly as to when blood sugar changes. You can determine how much to give yourself prior to a meal and anticipate how much to give yourself after a meal. The problem that is not understood is that the costs go up significantly if you are not on this therapy. So either they pay now or pay later. Since presumably the cost will be higher in the future it makes fiscal sense to pay now. Insurance companies do not want us as clients. Why would they? We are not profitable. However, even with the higher cost they can still eek out a profit with the coverage of a cgm and pump combo. I do not see a Dr. regularly. Why? I have the pump. I do see a Dr. to check my cholesteral and blood pressure and get my performance score (A1C) I do not see a Dr. for advice. I use the Dr. as a mechanic and a diagnostician. We make the proper adjustments and if we do not we end up costing the insurance company more money.
Once you are on the system for sometime you will become more comfortable knowing that it is accurate. In the beginning I would use strips more often to check accuracy. Now I know better. I use 3 a day and about 10 when not on the CGM. It is all about trusting the source. If you cannot trust the technology then it is not good technology. If you know the limitations of the technology all the better.
Try sending this article to them, it is documented research that CGM devices help diabetics
http://www.scienceblog.com/cms/study-shows-cgm-devices-also-benefit-people-type-1-diabetes-21474.html
Also on the minimed site they have this link
http://www.minimed.com/help/insurance/productcoverage.html
Which has loads of info, take notice to the ones from the FDA stating that the product has been tested and is clear for use in humans. Also note that the FDA came to that conclusion in 2005.(doing this debunks their “testing” approach) My insurance declined me also the first time, and they gave the same reason. I appealed, they lost the paper work, I appealed again and got approved. Another thing that I did note in my appeal letter is the fact that financially there is little to no difference between testing 12 times a day with the normal methods and using a cgm device 24/7 and changing it once every 7 days. Keep going at it and remember that 80% of all medical appeals are approved.
Thanks for the info. My prob is that my insurance was paying for the sensors for about 1.5 years. I placed an order with medtronic based on there advice of the sales agen that my insurance would cover 2 extra boxes and all of the sudden I hear the AMA changed the status of sensors. So now I’m screwed. I will send them the article plus medical records plus whatever else I can conjure up.
By the time you’d be costing the insurance company money if they don’t cover you, you’ll either be on someone else’s insurance (having changed jobs, or your job having changed insurance carriers) or uninsured (part-time or unemployed, company dropped all benefits, working as contract/freelance worker without benefits) or on public insurance (Medicaid, Medicare) and therefore not costing that particular carrier at all. It’s a short-term business cycle, and if they can kill us off before we start costing them any real money, so much the better.
Also, if you are no longer a diabetic, you still are a diabetic to the insurace company. So if i cure myself and no longer need insulin then I am still stuck. A friend cured himself so as to not need insulin any longer. He has MODY diabetes.
Make sure to check the minimed link also and send them the FDA info which says it is no longer in testing. FDA says one thing AMA says another.
Is it safe to assume here that your friend is T2?
BC the idea of someone stating that a T1 has cured themselves from needing insulin makes my brain hurt a bit…and quite frankly just adds to the confusion of the diff btw T1 and T2.
http://www.phlaunt.com/diabetes/14047009.php
Anyway MODY diabetes basically means he makes the long term insulin and not the fast acting after meals. So he would only take insulin after meals. It is a genetic problem. He and sister have it as well as his father. His brother does not have it.
He really got sick of taking insulin. By sick I mean angry. Just did not want to take it any longer. What I mean by cured is not making the faster acting insulin it was a change in diet and lifestyle. He decided to try a raw diet
He also developed his own blood sugar tester. So no strip purchases for him!
In either event getting your metabolism up to a high rate is the key to not taking much insulin. I also take Klamath Blue Green Algae. I highly recommend it. I am looking into a special form of proteolytic enzymes. The Drs name is William Wong. http://www.totalityofbeing.com/FramelessPages/Articles/TreatingDiabetes.htm
We are defective. Remember that. Know that you can get balance through hard work and discipline. Diabetes is the ultimate lesson in discipline.
Hey Jack thanks for the clarification on “cured” and the education 
I was not aware of this particular form of D - I didn’t know that was the deal with 1.5/LADA.