Why Insurance Companies Deny CGM Devices?

When we learned about the news that another person with diabetes had been turned down in her request to her insurance company to cover her CGM (Continuous Glucose Monitoring) system, we had to raise our voice. This time it was Kerri Morrone, but there are just TOO MANY people with diabetes that are having to go through this, and it’s completely wrong!

I too was just turned down for a CGM by Cigna for the exact same reason. This device has FDA approval, so how can they deny it?

I have been type 1 for 44 years and am hypo-unaware at least half or 3/4 of the time. I supplied Blue Cross Blue Shield of Florida with a letter of medical necessity from my endocrinologist. After sending it twice to Dexcom and following up, BCBS called it experimental…hmmmm, Ive been on it for well over 1.5 years and close to 2. What that means is that I get to keep paying cash every month for the sensors.
I think the true sin here is that the U.S. government does not allow your medical expenses to be tax deductible until it is 11% of your gross income. Taxing my medical supplies that I am forced to pay cash for is even more sinister in my opinion. Since I am self employed, I am at an incredibly high tax rate as all business income/profit is seen as personal income(let me assure you, it isn’t).
It equates to me paying 35%-40% more than the listed price of the sensor(income tax they cahrge me)…the true cost of the sensor is $84 dollars, not $60…I believe that is immoral.
With 5 children(that I don’t get to deduct), a home morgage (that I don’t get to deduct)High medical costs(that I don’t get to deduct)…I am tired of carrying the load and then getting slapped for my medical costs as taxable. Wanna lower the cost of your medical care dramatically…it should be non taxable and totally off limits…
Keep Going…Peace, Bob

I certainly empathize with this situation, and I haven’t tried largely because of this is the situation, but I responded to Manny’s post on this topic already. Let me play devil’s advocate for a moment. First, let’s look at the situation from a business perspective: the insured patients are, 99% of the time, NOT the insurance company’s customer, rather it is the employers who buy the policies, and they are under pressure to keep costs under control or they risk losing customers. Its no secret that the insurance companies have a fiduciary responsibility to make a profit for their shareholders (which, by the way, are what many of you’re 401K’s and/or pensions are invested in, incidentally), and frankly, they make money, but not on a ROI basis at a comparable level to the drug and medical device companies. The insurance companies are forced to view this from a business perspective, and Gina is right to a large extent, they would for the most part, rather us have complications. Insurance is all about managing odds, and the simple fact is that by denying this coverage, the odds are in their favor, because chances are extremely high that you will not even be covered by them when complications actually do strike. First, many people are likely to have several insurance carriers over the years due to job changes, or simply because employers negotiate deals with new companies (see my post here for more on that. The simple fact is that in most cases, those costs will be soaked up and paid for by Medicare, so our tax dollars pick up the cost, but few if any insurance companies will be saving much of anything by paying the cost of this costly technology, rather, they have everything to lose by paying it and stand to gain little if anything by covering it.

No one seems to question whether we’re being sold an overpriced lemon here? This technology largely relies upon interstitial fluid for readings rather than plasma blood glucose measures, and they price these things at several thousand dollars each … plus, the bigger expense is the roughly $35 per sensor (when chances are, they actually make them in China for pennies on the dollar), which need to be changed regularly (they recommend every 3 days, though most people get by fine at once every 5 days) for perpetuity – that adds up quite fast.

In my opinion, the real crooks here aren’t the insurance companies, but the manufacturers of this costly technology – no one is denying them the chance to earn a profit, but they don’t have to rape, pillage and plunder us and our healthcare providers in the process?! Let me add that the only way to really effectively address this is to abandon the for-profit insurance system we now have … something I’d LOVE to see happen, but I doubt we’ll ever see it! The odds are that we still won’t have universal coverage by the end of 2009, regardless of who wins the White House, because we’re now so far into debt for the Iraq war that whoever is in the White House or in Congress will really have their hands tied as to what they can realistically hope to accomplish. Who should we be thanking for that?

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I have aetna, i heard that United Health care is approving.

From a strict business point of view you are right, Scott.

The reason insurance companies deny people CGMS today and used to deny pumps before is because they can, so I do agree that the way to get out of this situation is for our health to be treated as an item that has a dollar tag on it.

One thing that I am not sure I completely agree with is that the product is a lemon. Overpriced, it could be, but having a device that helps you follow trends helps big time with better control.

Aetna paid for my Receiver and 4 boxes of sensors…(one box with my receiver/transmitter claim) and then 3 boxes on an additional claim.

Now they deny everything. Saying long term use is not covered. This is the exact except from their policy—they pay for 2 sessions a year—not sure if the hassle is worth it. My endo is set up for a peer to peer discussion about my case specifically----she will talk to the dr at aetna.

Continuous Glucose Monitoring Devices:

Aetna considers continuous glucose monitoring devices (e.g., MiniMed Continuous Glucose Monitoring System, Guardian Real-Time Continuous Glucose Monitoring System, and the DexCom STS), which are used to continuously monitor diabetic persons’ blood glucose levels over a three-day (72-hour) period, medically necessary for persons with type 1 diabetes who have either of the following problems in controlling blood glucose level, unresponsive to conventional insulin dose adjustment:

repeated hypo- and hyperglycemia at the same time each day; or
hypoglycemia unawareness.

No more than two CGMS monitoring periods are considered medically necessary within a 12-month period. Aetna considers the long-term use of continuous glucose monitoring devices for home self-monitoring of blood glucose experimental and investigational.

this was last reviewed 6/10/2008 and will not be review again until 1/22/2009

I was recently approved by Tricare for a CGM. If anyone has Tricare look into it. Tricare is approving the CGM on a case by case base. Like everybody says, if you have hypoglycemic unawareness or you titer tarter all day it should help with your approval. It took a month to get approved and my endo wrote a letter to Tricare to express the necessity of this device. My endo also pointed out that my husband and I are planning on having a baby in the near future.

Let’s say that instead of losing money, they are really making 10-15%. That is still within or well below what the government is charging us…10-40% on top of the cost of the medical supplies. Medical should not be taxed espescially as the cost of health care is climbing dramatically.
I want Blue Cross and Dexcom to make a profit as they are providing a product that I want to be able to buy next year too.(No profits–no sustainable company).
It’s the added cost of 10%-40% that the government takes…a much greater profit margin than most companies ever see…

Minimed called me to say they are starting to work on a CGMS for me, but I know medicaid will usually say no. I will appeal this repeatedly and will continue to do so.

I think in my case, it may be slightly different as this is state/federal SSI insurance. But to see others who PAY their premiums and such get turned down, that’s really bad!

I actually expect no’s and learnt to circumvent around them. Paying for this is out of the question right now, but soon I would be able to. If they covered the Transmitter, I could pay for sensors occasionally.

If I can’t rely on insurance to help me, it’s all I can do.

I also was denied, after 40 years with this, but to keep myself nder as close to perfect coontrol, I purchased it on the payment plan that Minimed will let you do. It’s only $50 a month that way! If anybody wants more info I can get you my reps name.

I could use the info, I was told to ‘just put it onto a credit card’… Like if I HAD a credit card, I still would not. If I find a bank account that PAYS 22% interest, I would think about it. But when they told me to just put it onto a credit card and they don’t have a financing plan, I felt a bit slighted.

I’m in Orange County, CA, and apparently my reps’ Shannon Smithson. If your rep can help out if I get denied, that would be brilliant!

I just saw this posting, I know, a little past the original post date, but felt I needed to chime in too…
My daughter is covered by Cigna and we, as well, followed all the proper steps of getting the Letter of Medical Necessity from her Endo, with a formal request, talked to the MiniMed rep… And of course, got denied, for the same reasons as most do, because CGMS is “not approved and because it is experimental”.
When you get denial, you are also given an opportunity to appeal. So I put together a very long letter, working around the denial reasons. I provided the data on FDA approval, on the results of using of this “experimental” device in clinical studies, and so on. I also added some personal history on recent extreme hypo episodes. I gave specific examples with the glucose readings, dates when it happened, etc. More data than they needed. Followed by some phone calls.
Guess what? We got 100% approval! I was also told we were the first in our state to get approved coverage by Cigna.
Now, getting the actual CGMS shipped was a whole another story. Because we were “first” no one knew how to handle the billing, even though everyone agreed it was covered…

I wouldn’t say Ever" You will be 18 soon and in the meantime, a start to gather info for your fight. The way Insurances are starting to cover this puppy, who knows WHAT will happen in a few months? If it is your parent’s insuring you, perhaps they simply can’t afford it what with co-pays and all… have you had a chat with them about this, and maybe when you see another Endo, they too will be able to help you…

Can you please tell me what state you are in - I have Cigna as well and they actually approved my CGMS and sensors back in December of 2007. When I went to place a new order for sensors because my others were almost gone and about to expire, I was denied. I have been through the appeals process before and now they tell me that according to a new review, they will begin approval on August 18, 2008 if deemed medically necessary. My doctor has to call along with alot of other hoops.

I too have severe hypo episodes which is why I want the CGMS so badly. Any additional feedback you have is greatly appreciated. Congrats for you and your daughter. Rebecca.

I am too fighting for coverage from Blue Cross Blue shield of Texas who insists that it is experimental. I had my appeal turned down today even with police reports, ems, letter of medical necessity from endo, fact sheets, letter from me stating my case and still denied. I have hypoglycemia unawareness and it has cost me so much the last couple of months. I wish i knew what i could do to fight the insurance company. So far they are winning.

I was recently covered at 90% w/ no fight or appeals or anything by Aetna. I am in Texas but have a federal govt. Aetna plan. Maybe the solution is to work for the government? Seem to treat the employees much better than the average citizen.

I am a state employee and is quite surprised at how bad the insurance has turned out to be.

I love the analogy about a song. That was beautiful, Manny.

I’m still waiting to hear if I’ll be able to get coverage of my sensors again…