It's been a while since I've been here but I plan to post more regularly. One issue I'm particularly focused on is having been rejected for a CGM. My endo recommended it but my A1c's are "too good" and I can still recognize lows. So (says the insurance co) lets wait til they're not and then we'll give you the Dexcom. As someone who's had T1 for over 22 years w/no complications to date, this is tremendously frustrating. It's A LOT of work to keep good control as we all know. I'm tired. Why can't I have technology that would reward me for working so hard not to mention help me stay in control? I'm also dealing with pericarditis-more stress-but that wasn't enough to get me the CGM either. Harvard Pilgrim has rejected me 2x. I will still appeal but curious if others have gotten it despite lack of "complications."
Just keep fighting
You should get it as a prevention
To me, a t1 diagnosis instantly qualifies for CGM. I would find a sympathetic endo which shouldn't be too hard. Both of the endos I have used did and would not hesitate to pursue Dexcom for me. The endo really needs to support you because they know how to submit the paperwork as medically necessary. As for your insurance, this is unfortunately a game they are allowed to play. In case you don't know, if you keep appealing, the insurance company will be forced to have an M.D. certify that CGM is not medically necessary for your T1 and it no longer becomes a game of the insurance putting off payment and instead an M.D. has to put his license on the line in deciding your case. To me, CGM isn't just about avoiding complications, it is about the peace of mind of knowing where my bg is headed no matter what I eat and how active I am. This is something that non-PWD's cannot understand what it is like to live with this unrelenting condition forever. I would keep appealing and while those appeals wind their way through bureaucratic channels, I would put it out of mind and go on with your life! Good luck!
Welcome to my life as a T2. My insurance (Aetna) considers a CGMS as medically necessary for a T2 only when you are hypo unaware or have repeated highs and lows. Aetna does consider CGMS use as medically necessary in adults with T1, but not T2s.
I was able to locate the Harvard Pilgrim policy on CGMS. Unfortunately the criteria that is required is that you must display poor glycemic control or have hypo problems. If you read further into the policy there are two directions to pursue. The first is to argue that in order to optimize control the CGMS is needed. Perhaps arguing that you are considering having a child and that you need to get your A1c down to below 6%.
The second option is that the policy does "grandfather." If you purchased a CGMS I suspect you could get them to cover the supplies and subsequent replacements.
In either case, your insurance totally rejects the use of CGMS for T2s so don't feel that bad.
Thanks to both of you-Don, you voiced my feelings exactly. My endo is sympathetic but I let the Dexcom rep handle the interface btwn them, the endo and the insurance co but I don't believe she did a good job-at one point telling me being rejected for low A1c's is "typical" and "just how it is." Typical, I get, "just how it is" just makes me determined to get one.
Thanks and have a wonderful day!
Brian:
We should fight that too! Thanks for the extra research.
Valerie
Valerie, you're beating one of my favorite drums. My insurance has the same problem Brian's does, probably because it's the same company. Actually, though, this is pretty much an industry-wide phenomenon. Most insurers simply won't consider a CGM for a T2 unless you can document a history of severe highs and/or lows. Hypo unawareness helps to convince them too. Fortunately or unfortunately, my control is too good for any of those convincers to apply.
And like Don, I don't see good control as a valid excuse in any event. If your control is good, isn't it in the underwriter's interest to do everything possible to help keep it that way, for as long as possible? Sorry. Just ranting.
David:
I have the same rant. "Control" is a dumb qualifier re diabetes because yes, if insurance companies were truly interested interested in health they would focus on prevention and provide the supports that keep people w/diabetes healthy.
I'd love to make this a campaign...
Valerie