Hey guys! Ive been wearing my dexcom for about 2 days!, Im in love with it already, Its has been really accurate and has caught 3 lows for me already!. My insurance doesnt cover it. Im only wearing this for a week. BUT I want this more than anything in the whoollle widdeee worlddddd!.
What could I do to make my insurance cover this?
Check your insurance’s website for particulars about coverage. I think I googled “interstitial fluid” or “continuous glucose” and my insurance name. Here’s the page from my insurance company.
Here’s the basic gist from mine. It’s pretty standard:
"Long-term use of continuous interstitial glucose monitoring devices as an adjunct to standard care is considered medically necessary in the care of the following:
Patients with Type 1 diabetes who have experienced recurrent episodes of severe hypoglycemia with blood glucose less than 50mg/dl; or
Patients with Type 1 diabetes who are pregnant, during the course of the pregnancy;
When all of the following criteria are met:
Inadequate glycemic control despite compliance with frequent self-monitoring (at least four times per day) and including fasting hyperglycemia (>150 mg/dl) or recurring episodes of severe hypoglycemia (<50 mg/dl). This poor control is in spite of compliance with multiple alterations in self-monitoring and insulin administration regimens to optimize care; and
Insulin injections are required 3 or more times per day or an insulin pump is usedfor maintenance of blood sugar control; and Four or more fingersticks are required per day."
Since you’re unlikely to get pregnant, document your lows and your frequent testing like a maniac. And appeal, appeal, APPEAL. You will eventually win.
Well, Kenny, the first thing you’ve gotta have is your MD documenting that you’re doing fingerstick testing A LOT, and you’re fully trained and compliant in carb-counting, and that you’re still having problems which constitute a"medical necessity":
A pattern of severe nighttime hypos would constitute a good basis claiming “medical necessity”, because the only alternative treatment which exists (i.e., waking up every hour or two for another fingerstick) is itself a huge danger to the pt., and possibly to others as well AND to others (e.g. car accidents and power equipment accidents due to sudden drowsiness).
Another very good basis is hypoglycemic awareness-- falling all the way into “dangerous condition” without enough warning signs to even realize you need to test and/or take action.
Sudden and Severe glycemic changes is less strong, but maybe sufficient IF they are shown to be totally unrelated to bolus insulin and incorrectly estimated food (i.e., to be something which happens to pt. for no apparent reason).
And finally, any ADULT (>25) with pre-existing good treatment habits (careful, properly calculated, and aggressive) who still has A1c above generally accepted “target levels” can refer to the new NEJM study (the JDRF-sponsored one) as evidence for long term CGMS usage, by pts. just like you, providing significant improvements in A1c from just CGMS, with all other factors (training, review, and follow-up) kept carefully equal between study and control participants. For A1c above 7.0, this can be a showstopper all by itself. For A1c 6.5 to 7.0, it’s a harder fight, because ADA recommends a target of only 7.0 … another reason to send your contributions to JDRF instead, IMO.
What did your MD check off on the Dexcom-provided prescription questionaire? How should ask for a copy, and tell which criteria were specified. Post back, and we can go from there. (Hint: I’ve posted about this here before, look over some older discussions).
And finally, what insurance company (and what State, if it’s a multi-state provider) are you covered by? And, if via employer, is it a “self-insured” policy?
And why is this long, long ,long story of BCBS internal “We really care, look at all the Defibrillators!” of any relevance to CGMS?
I’m making a slightly mean South Park reference, of course (the famous “Look at the Wookie!” defense). But please respond, I don’t understand why you posted this-- and I really suspect that the problem is at MY end. Please ???