Pulling my hair out

Not literally. But it made you read this discussion, didn’t it?!?

I received a call from a Dexcom representative about a week ago, telling me that my latest sensor shipment wouldn’t be processed until my Dr sent a code they needed for Aetna to help pay for the shipment (Aetna primary thru school, BCBS of SD as secondary thru Papa Willie). The rep said she’d contact my doc, get the paper work, etc then call me back when things were a go. I was slightly confused because we’d just (in March) re-faxed the prescription code to Dexcom for this same issue. Anywho, I let it slide because I was going to be traveling back to school soon and had a million and one other things on my mind.

Fast forward a week, and I receive another call from the rep saying my dr didn’t want to give the code and that Aetna probably wouldn’t pay for the sensors. She seemed a bit mystified and offended the doc didn’t follower her direction :slight_smile: I told her, knowing my stubborn yet very attentive doc, I would look into it and let her know what we could do. So I emailed my doc and she said that Dexcom was asking for a “frequent severe hypoglycemia” code and #1 I have not ever had a severe episode (knock wood) in my three years of T1D nor did I have documentation of frequent hypoglycemia and #2 the health center doesn’t even have that code in their computer system!!! She wrote me a “uncontrolled diabetes” code (I’ve not had an A1c <7 in about a year (uncontrolled in my book)), but said she wouldn’t do much else. And on this I am with the doc. I do not know how I’ve gone a year with Dexcom and not run into this code problem before now. Perhaps it was those “make up a few <50mg/dL numbers” that I fudged (on a recommendation from Dexcom when applying for the sensor) a year ago that tided me over until now.

If I have to lie (again I guess) in order to get what I want/need, I won’t be able to do it. Has anyone else run into this problem? Isn’t it frustrating when realizing such an awesome and life-changing technology can be taken so easily from your tool kit? It’s pretty dumb that just because I do not have “frequent” hypoglycemic episodes I won’t be able to use a sensor which could literally save anyone’s life (regardless of documented history of hypoglycemia). Perhaps this goes back to the idea that, in health care’s eyes, hypoglycemia is more of a risk (malpractice?!?) than hyperglycemia. I’m not saying hypoglycemia is not an immediate threat (it is, undoubtedly), but does that mean hyperglycemia is not just as (long-term, specifically) dangerous and important to treat?

If you’ve read this far I thank you. And as I reread my post, I realize others have probably written about the same frustrations.


hi willie, I have read your account 2 times and i know you are making some critical and important points but i dont get it. Can you, if you have the time, write a bullleted points of the meat of the issue…?

yes yes yes. i wrote this while i was a bit upset/flustered/angry. bullets to come soon.

DEX representative: your doctor won’t give us the “frequent severe hypoglycemia” code Aetna Insurance requires for them to help pay for the sensors.
MY doc: you don’t have “f.s.h” so I will not use that code
ME: I don’t want to lie about this and I shouldn’t have to lie to get sensor coverage

I told DEX rep that we had decided not to use the code because it would be lying. The DEX rep was upset and mystified.

MY ?s: Is there any way to have a sensor paid for if I’m not experiencing severe hypoglycemic episodes? Has anyone else not used the code and received insurance coverage for a sensor? Has anyone else been asked by DEX to lie about their numbers in order to get coverage?

sorry that you have to re write.

since the insurance are looking for ways to deny, you have 2 choices in my opinion; lie or create self-induced hypos and then record and send it to them. I dont know any other ways to go around it. We all have had hypos we never recorded, so if they tell you to find 4 hypos in a month, that shouldnt be a a problem. That can’t pass for a lie!

If all else fails, maybe you can switch docs?

If your doc had T1 himself, he would not be a stickler. Non-T1 have no idea what it’s like.

When thinking about what to do about something like this anyone would be coloring in shades of gray. Perhaps you could just be a bit more aggressive with your carb counting or go out for some serious exercise? Not with the SPECIFIC intent to cause a low but we all know that these are clearly situations when you might have a substantial low on the other side. I do not know. This is a tough issue.

They should make it easy by giving all T1s a CGM. It’s a life saving tech…

I used to have severe hypos, but now with the Seven+ I get an alert so I can treat the low before it gets severe. Is this happening to you? If so, maybe you can use that to get insurance to pay. I cannot find a report in DM3 that indicates how many low alerts I have had, but Dexcom might be able to retrieve that information if you upload your data.
I just checked the DM3 export file, and unfortunately the alerts are not written to the file. I can’t find my documentation file to see if there is a way to include alerts in the export file.

I ran the Dexcom Modal Day report, and circled the minimum readings <50. I also ran a report from OmniPod software that gave actual blood sugar readings below 50, and sent both reports to my insurance company with my appeal letter when they denied my Dexcom after I had been using it for a year. I also CC’d Dexcom. I won the appeal. In my letter, I emphasized that when I had the low numbers the Dexcom alerted me or my husband to the impending low in time for action to be taken before the low got to the point of needing outside assistance.