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First-Level Appeal Letter re: Dexcom Denial.

Hear me.I received a letter today from Oxford Health Plans, denying my request for CGM coverage.  "Our Medical Director has determined that the request is:  Denied - Not Medically Necessary."

My First-Level Appeal letter is below.  This is the first round of a potentially long battle, but I'll see it through as far as I can, I promise.  A price tag on my health?  I don't think so.  Here's hoping they listen.

"June 17, 2008

Clinical Appeals Department
c/o Oxford Health Plans, Inc.
PO Box 7078
Bridgeport, CT  06601-7078

To Whom It May Concern:

On September 11, 1986, I was denied a normal childhood when I was diagnosed with type 1 diabetes.  My parents were taught to measure my food, test my blood sugar, and inject insulin into my body.  We were taught about diabetes complications and how they may end my life.  We were taught to plan for the worst and hope for the best.  This was my mortality, handed to me when I was just a child.

On January 27, 2003, I was denied the ability to control my blood sugars with insulin injections alone.  My medical team determined that my diabetes would be best controlled with an insulin pump instead of multiple daily injections.  Thanks to my hard-working medical team and my personal dedication to good health, I started using an insulin pump.  My A1Cs have been lowered and my risk of diabetes-related complications lessened, thanks to the benefit of this technology.

On April 15, 2006, I was denied the symptoms of a low blood sugar while I was at the movies.  Thanks to my years of hard work and my desire to keep my diabetes as well-controlled as possible, my body was less sensitive to the symptoms of low blood sugars.  Therefore, a blood sugar of 27 mg/dl snuck up on me without warning, leaving me moments from a diabetic coma.   Currently, I experience severe hypoglycemic unawareness, leaving my body at risk for potentially lethal, undetected low blood sugars.

On May 18, 2008, I was denied a wedding without diabetes.  Surrounded by friends and family, and with my husband-to-be standing proudly at the front of the church, I walked down the aisle.  My mother cried, later admitting she always feared I would not see this day in good health.  My blood sugar plummeted, without warning, before the first dance as a result of my excitement.  I did not feel the symptoms.  I spent my first dance with my husband clinging to his arm, trying to focus and waiting for the glucose tabs I had just eaten to raise my blood sugar.

On June 13, 2008, I was denied health insurance coverage for a continuous glucose monitor by Oxford Health Plans. 

I am twenty-nine years old and have spent more than two decades living with type 1 diabetes.  My wedding was barely a month ago.  I am so excited to start a family with my loving husband.  I will not be denied the chance to have a healthy pregnancy.  I will not let my mother be denied a good night’s sleep because she’s worried her daughter will have an undetected hypoglycemic episode in the middle of the night.  I will not let my husband be denied a healthy wife. 

A Dexcom continuous glucose monitoring system receiver costs $800. The sensors cost $240.00 for a pack of four.  Over the course of a year’s non-daily use, the Dexcom system will cost approximately $1,800.00.   

Compare this cost to that of laser surgery to treat diabetic retinopathy.  Or the cost for kidney dialysis or transplant.  Or the cost of daily medications to treat high blood pressure, cholesterol elevation, or kidney disease.  Or the cost of an amputation, as well as any attendant costs for rehabilitation and lifestyle adjustment.   Please be advised that keeping me healthy now will save your company from greater expense later; preventative measures taken at the present time will mitigate the overall financial loss your company would otherwise incur in the future. 

Denying my claim to protect your company’s bottom line is to deny my chance for a long and healthy life. You have marked my claim as 'not medically necessary.'  You have boldly put a price tag on my health. 

Your denial may cost me my life.  I urge you to reconsider your decision.

Sincerely,
Kerri Morrone Sparling"

Comments

These words eloquently sum up the experience of your life with diabetes. But they also echo many of the experiences we have all had over the years. The moments of our lives when diabetes couldn't be put to the back burner, no matter how much we wanted it to. This letter was very well stated and poignent.

I have been continually frustrated by the response of insurers to the advent of CGM technology. Hopefully, as more data emerges, this will be covered the same as a standard blood glucose meter. I remember ~10 years ago trying to get strips covered, so there is precedent (or a history of ignorance) for later approval of new technology.

Keep up your fight. The more letters that we each write, the more likely it is that our children won't have to fight these battles.

No diabetic should be denied the right to technology that can improve their quality of life.

I think you're letter was extremely well written, Kerri, you shouldn't have to fight, but unfortunately you do, and I know you can put up a tremendous one.

We are all behind you 100% with what ever support you need =].

Very well written. Don't stop fighting!!!

fantastic letter but to convince them you need the CGM you may want to give even more emphasis to the hypo unawareness + pregnancy plans. Since you have a great A1c they may not be so generous if they feel you are not at high risk for long-term complications. But with hypo unawareness and pregnancy it is clear that this would be medically beneficial. I think it is a moving letter but I don't think health insurance companies, in general, are that sympathetic. Also, if they are covering test strips for you there would probably be a decrease in cost for those; although I think most insurances have contracts to get the strips dirt-cheap.

Anne - Thanks, and I agree with you for the most part. My doctor is writing another letter of medical necessity with a heavy emphasis on unawareness and pregnancy. There are also several rounds to an appeal. This won't be the first letter I send. Or the last. ;)

You may want to strike harder on the "undetected low" drum... a "good" Hba1C can hide frequent hypoglycemic episodes.

http://www.liebertonline.com/doi/abs/10.1089/dia.2005.7.780

Good for you!!!! I hope this gets some attention. How frustrating to be told that the CGM, which we've all been wishing for over the long years and is now finally here, is not medically necessary. Excuse me, but when you can feel a low blood-sugar, it is extremely necessary!!

Great letter, Kerri! Go get 'em....on the CWD forums, several people have beaten the denials by inundating the insurance company with studies and data that show CGMs are effective, cost-saving, etc. You can always just bombard them with data until they give you the OK just to get you to leave them alone... ;)

I haven't yet taken on the insurance fight for my dd's Dexcom...I'm still working up the gumption. :)

Honestly, it's a nice letter, and eloquently stated as everyone said, but I'd cut it down to about half as long, lest they not read it at all. As much as we care about your wedding, they likely don't. I'd include the info about why you need it (hypo unawareness), and how it will save them money.

1. Look up the appeal process in your benefits booklet. Plan for, and collect support data and documentation.
2. Be prepared to prove hypoglycemia episodes. Use BG meter logs/EMS logs(in case you had to call 911) along with your endo's letter of medical necessity
3. The Health Insurance companies make it difficult and expect you to give up.Don't. Read their rules, and play their game. You will win.
Best of luck! Go get 'em!

Excellent letter. I am tempted to use this blog entry in my English 102 class where I teach research/argument.

This is SO WRONG, Kerri!

I just posted a video about this on TuDiabetes.

Thank you guys for all of your feedback. This letter is just part of the appeal process. Over the next few days, I'll be compiling all of your suggestions into a concise packet for Oxford - and hopefully with your helpful advice, this approval won't be much of a process. :)

Keep the suggestions coming, and if you've had any luck getting covered, please offer your advice. THANKS!!!

That is a damn good letter. Let's pray I don't have to write one too!

Kerri, You are a hero to so many of us.

Kerri

You'll probably also hear that there's no proof of the efficacy of CGMS. On the Dexcom site you'll find several papers showing the results of studies.

I say, drown them in paperwork.

I imagine that was a hard letter to write. You did it very well. You know we're all pulling for you (and us) in this.
Here's to the insurance industry coming to their senses.

Hey Kerri,
I have a friend with lots of $$$$ who goes to Yale for diabetes care. Her daughter did the first closed loop test with great results. She wanted to bring the same program to Chicago and had the pull to have all the powers that be at Northwestern to hear the Yale presentation and how we could have leading edge in Chicago. The CEO told her "no Way" We make our money on complications. How sick is that.\
Carol

Kerri,
As a RN Case Manager for a TPA (administrator for group health plans) and mother of a 4 year old T1 I am SO glad you are fighting this! Your letter is perfect....sadly, based on my work experience, I can say that the bulk of your letter will not impact them. However, they are going to listen up once they see that the CGM and supplies will only cost $1,800 a year compared to the potential costs of laser surgery, amputation, etc. And if that doesn't help...please feel free to add that the average cost (per HCUPnet http://hcupnet.ahrq.gov/HCUPnet.jsp) for a hospitalization for hypoglycemic coma is $22,676.00.....that might help get their attention if its sent along with documentation from your endo regarding your hypoglycemic unawareness! It helps to wake up our medical director :-) Please feel free to let me know if I can help you out in any way...I at a conference right now and am going to a session tomorrow on CGMs! And good luck!

awesome letter...keep fighting!

Kerri,

Your letter is as touching as it is poignant. Your fight encourages the rest of us to fight, and it is so frustrating watching something like this unfold and not be remedied as quickly as it should be. Thank you for putting yourself out there with this blog, it is truly more inspirational you may ever realize.

Kerri,
They don't care about you,do not let that fact get lost on you in your fight. There are none so blind as those who will not see.
Give them numbers.
Document the unawareness problem by blood sugar logs. Bombard them with numbers. Thereby making it a medical necessity
There lies your trump card,I believe.
The other problem I think worth mentioning is that the cost of the sensors is obscene. Included in the price has to be the years of expense incured in makling this technology available. The price must come down.
Mark

wow! that is very well written and hits to the core of the issue. powerful stuff!

I think the letter is perfect. I'm taking notes, I'm sure our fight is right around the corner.

Go get them Kerri. I hope you can get this taken care of without too much more on the appeals process. Good Luck!

my sweet little miss kerri, NOT FAIR that you have to go through this. i just got to read this at 11:30 at night, and am reading it with tears running down my cheeks. i just want to go do mean things to that Oxford Health Medical Director. how dare he? if anything happens to you because you don't have the CGMS, i swear I will personally make that director's life a living hell.

Kerri

I notice that CGMS central has a post about Oxford covering the CGMS for someone in New York. Check it out here

http://cgmscentral.com/node/66

Rock on Kerri.
It hit home with me, big time. Ya know, the denied at 6, the struggles and over 2 decades later at 29 no health insurance, no chance in hell of ever seeing a CGMS...

Keep on fighting the good fight...

Thanks, you guys. Your feedback, as always, has been tremendously helpful.

I'm hoping that this discussion can help me, and everyone else who is aiming to have their CGM covered, achieve the coverage we need - and deserve. If you are embroiling in an insurance battle re: CGM or any diabetes device, raise your voice!

BRA-FRicking-VO!!

I have a suggestion that may help you in your battle. The website Consumerist.com regularly posts articles about the hassles patients have dealing with HMO's (among other types of *cough* customer service *cough* providers.

It would also be beneficial for others fighting the same fight.

They also often get very rapid response to problems because the HMO's are starting to monitor the Consumerist web site for potential black eyes.

http://consumerist.com

Good luck with this, Kerri. I know it will be a long process but I agree, the more emphasis you and your doctor can put on numbers, the better.

I've faced similar battles in getting coverage for the daily chest physiotherapy that helps me clear the infected mucus out of my lungs, keeps me out of the hospital, and makes it less likely my infections will be life-threatening (and I've enough near-death experiences to know what a difference chest PT makes). But, as someone pointed out to me, we need to think about how the companies view things to fight this fight. It makes so much sense to us that they will save money later by giving us the tools we need now to manage health, but they see such tools as a fixed, given price. And they'd rather not pay a fixed, definite price when they can gamble on those expensive complications not happening.

Argh!!! Keep on plugging away!

Fantastic letter, Kerri!

I'm a little steamed by this post on your appeal letter and the other 'stuff' that it's mentioned along the way.

I hope the link comes through in my comment, because I suspect I'm not alone.

Good for you!! I am cheering for you.
Your words have empowered me to write to my insurance company to possibly fight the fact they won't pay for my Avastin shots in my eye for my diabetic retinopathy.

I'm glad I live in Canada

yah it is better to live in Canada because they got better health care coverage.

Well written. Keep fighting Kerri! My 20 year son's CGM (Medtronic) is covered my our insurance - BCBS/Anthem.

brilliant, kerri, just brilliant. thank you.

Great letter. Our insurance company just approved us for the Dexcom! Two seconds of mental celebration when the Dexcom rep told me this. Total despair when she said they approved it as "out of network" ... i.e. subject to an additional $2,000 per year deductible. In other words we're approved but they won't pay a nickel. Sweet.

Canada does NOT cover CGM either! Kerri, what is the result of your appeal? I am currently fighting the same battle with my insuance providers. You're absolutely right, there is to be NO price tag on our LIVES! Email me, we can share data... bodyrings@gmail.com

R

Good job Kerri. Your success may save other people too. My brother died as a result of hypo unawareness two years ago. We never knew about continuous monitors, I don't know if it was even available then...it would have saved his life.

This post is so awesome. Glad I found it.

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