UnitedHealthcare PPO Approced CGM July 2014 and Now Denies (Type II Diabetes)

Diabetes Technology Glucose Monitoring
#1

United Healthcare Approved my Dexcom G4 system on 7/16/14. Since then, they have been approving my sensors every 90 days. My last covered purchase of sensors was on Jan 9th 2015. I have now reached the 6 month mark and wanted to reorder a transmitter before the battery dies.

I am Type II and My Endocrinologist does not accept any CGM data to make decisions with so I am unable to discuss trends, peeks and lows between finger sticks.

After submitting my request for the replacement transmitter, I received a communication that they denied coverage and I could have my doctor request a peer to peer review to prove I need this.

I asked and I believe my doctor may have followed through given I just received a letter in the mail from United Healthcare indicating coverage is denied.

It says being Type II and my recent records do not show a history of low blood sugars.

1. Why would they cover me and then when requesting a replacement transmitter drop me?

2. I have a general problem of blood glucose levels that are too high, not too low. I was using the Dexcom to help bring my levels down without going low. Now I have to record many low readings to re-qualify?

3. I am wondering if they just decided not to cover the transmitter but will continue to supply the sensors? If I knew they would continue covering the sensors I would probably but the transmitter on my own.

I am wondering what the best strategy is to dispute this and win. I don't know what I would do without this CGM. 4 data points per day just don't cut it. I find that my levels can look fine and then an hour later they are in the low 300's.

I am also wondering if I should switch endocrinologists to one that believes in using this technology. It would help to have someone help fight this for me.

Sigh

#2

You need a doctor in your corner to fight this for you, you have little leverage on your own. The idea that your current doc doesn’t want to see this data is baffling in its own right. So yes, it may be time for a new doctor.

If you previously documented lows to get this, it seems bizarre that they would want to see a pattern of lows while you’ve been on the Dexcom, because the whole point of the Dexcom is to avoid those prior lows. But a doctor would need to point that out to them.

Ultimately, what you need is a doctor who is willing to argue this is a medical necessity, and perhaps even include some language that will make the insurance want to cover its butt, such as related to safely driving.

#3

It may be possible that the criteria for cgms coverage for 2015 has changed for your insurance policy. My insurance has always required repeat documentation and preauthorization in the past and hypoglycemia below 50 is one of the criteria my insurance requires. They don’t care about high blood sugars in terms of cgms.

So even though the Dexcom has helped reduce my incidence of hypoglycemia I always made note when it occurred or printed it out because I knew that was what they needed. Or if there was a clear time that use of cgms prevented a severe low I added that to my file. That way when it came time to renew insurance approvals I had a lot of the documentation on file already from the past year that they required. It helps to know what your insurance cgms policy is. My insurance also required endo notes and bg logs etc so having a physician that is familiar with cgms and uses the data in their practice was certainly helpful.

I found it easier to collect the documentation throughout the year as opposed to going through several months of data at the time of insurance renewal.

If they deny coverage for a transmitter then I would assume they probably will deny coverage for sensors at some point too.

Good luck with your appeal.

#4
I am Type II and My Endocrinologist does not accept any CGM data to make decisions with so I am unable to discuss trends, peeks and lows between finger sticks.


Have you asked your endocrinologist why s/he is being such a silly goose about the CGM? Not feeling comfortable using the CGM independently for making dosage decisions is one thing. Completely refusing to discuss CGM data even in the context of accompanying, concurrent BG tests is ... unexpected.

If it were me I would first attempt to get a meaningful explanation from this doctor for refusing to work with the CGM data. There are studies available to support the accuracy of the Dexcom system and you should also have BG tests to support this in your particular case.

Ask for details. Don't merely accept a "not accurate" or equivalent brushoff. Ask to be shown repeated examples of the inaccuracies versus the BG tests in your data which prove the CGM cannot be trusted. If the doctor doesn't trust it then these should be there, no?

I think a calm, polite request to do this should be respected. If your doctor is not willing to do this, then I would question just how much use his counsel actually could be to you and would suggest moving on, if possible.

-iJohn
T1 LADA since ~1978; first pump 1997: Minimed 507; currently: Paradigm 723 + CGM

#5

Thanks. I didn't realize the main function of the unit was for lows. I guess that makes sense. But in my case, my problem is highs and I guess the guidance I get results in many highs. When I provide my data it is only the point before a each meal and before bedtime, So I don't include lows unless they occur at one of those 4 points.

When I have lows they are in the 70's, once or twice in the 50's. Is this low enough that it can be used to indicate need?

My real use for this is to understand what types of foods make me go high. Looking at trends and adding more insulin when I am trending high, seeing how excercise effects me, and general use to keep my highs lower.

One could argue that if I were keeping my highs in better control, I would also have many more lows.

#6

I didn't have to go through all of this to get approved in July. Maybe I was just lucky. The policy didn't change or they would have given me a hard time on my January renewal of 12 sensors. Maybe the person reviewing my request changed.

I will start submitting my lows although i suspect that will result in more rules and reduced dosages of insulin and higher highs.

#7

I didn't ask. It is most likely my own fault. There is a limited amount of time that I get and just have not been that aggressive about pushing it since I already had the device.

#8

I am a Type 2 and also have UHC PPO. Unlike the type 1's who usually have the high/low swings....for me, I have the Dawn phenomenon and since I got to bed with a normal BS and wake up with a high wackadoodle morning FBS...I was able to get it covered.

#9

1) Find a new doctor b/c
2) being on insulin should be the only reason your doctor needs to authorize your CGMS.

#10

My insurance company makes it almost impossible to get a CGM (requiring documentation of multiple lows below 50) and once you have the CGM, they require a review at 6 months for continued approval. The 6 month review must show that you are no longer have multiple lows below 50 (i.e., it must show the CGM is effective). Perhaps your company has a similar policy.

Like you, my problem tends to be highs. Thus, I pay for the CGM out of my own pocket -- my own, slowly dwindling pocket.