(This is a loooong post. And contains many terms that I just learned today.)
Dexcom and I are looking forward to being reunited (out of sensors at the moment), but before we can do our Dex-y dance again, I need to get this stuff covered by my insurance plan. My contact at Dexcom put me in touch with their insurance management team, and they've been working hard to get the proverbial ball rolling.
I spoke with one of the reps earlier in the week. She was very hopeful about insurance coverage, telling me she'd start processing the claim through Oxford Health (they are my insurance provider) and would touch base with me with the good news. I laughed.
"Good news? Let's be honest. There's rarely ever any good news when it comes to insurance ... anything. So let's assume they'll reject it, and we'll create a battle plan from there."
"Right. A battle plan! I'll contact you as soon as I have any new information."
True to their word, an email came in from Dexcom yesterday.
We have not had any luck in getting other patients through Oxford. We also tried to go through a distributor without any luck. So, we are going to ask Oxford for a predetermination or "one-off" approval. We may need to come back to you for more information should they request it. We will keep pushing on our end.
Your plan does provide for DME devices (the DexCom products are a DME benefit). However, you have a $1,000 deductible, with $0 met to date. After that, your coverage is at 70%.
Arghh - directed at insurance companies, not at Dexcom. $1,000 deductible, and even after that's met, a 70% coverage rate? Blast, that's pricey. And am I ignorant because I have never heard of a DME before? I asked my boss and she explained that DME stands for "durable medical equipment." I looked up these kinds of requests on the Oxford site and found the following:
"Durable medical equipment (DME)* No charge - Deductible and coinsurance"
Uh oh. What's that asterisk all about?
"These services require Oxford precertification. You must call us at 1-800-201-3080 at least 14 days in advance of request. Mental health and substance abuse services can be precertified through the Oxford Behavioral Health Department by calling 1-800-201-6991."
Okay, so that notation means I need Oxford precertification. What the heck is that?
Before I could research too much into it, another email came in from the folks at Dexcom. It was from one of the reimbursement managers and she carefully outlined what actions she had taken with my insurance company. She spoke with the benefits department at Oxford, the Medical Management Department, and letme know what the next steps are. I really appreciated her thoroughness and at least had a timeline to attach my frustrations to.
At this moment, my request for precertification is in play with Oxford Health, despite the fact that the Oxford rep told my Dexcom rep that the sensor codes are not covered by Oxford insurance. These are the hoops we must jump through? Blast again. The policy and rationale of Oxford's "nah, we don't want to" is as follows:
"Due to insufficient clinical evidence to support medical efficacy, the rental and/or purchase of continuous glucose monitoring systems for long-term use in the treatment of diabetes mellitus will not be reimbursed by Oxford. This service and/or device is not proven to be clinically effective and, therefore, is not considered to be medically necessary."
Not effective? Didn't this thing save me from losing it at the bank
? And didn't Chris say to me this week that he's glad I'm pushing for insurance coverage because he sleeps better knowing I'm protected on the overnights? And aren't these questions rhetorical? (Yes.)
Looks like the deck is a bit stacked against me at the moment. But I have the attentive staff at Dexcom on the case. And I also have a team of terrific doctors, both at Joslin and here in CT, that are going to go to bat for me on this. I'm currently drafting up a letter of medical necessity to be sent to my insurance carrier. And I'm also not giving up on this. Chris and I are a married couple now, and starting a family in the next year or two is in the cards. I experience severe low blood sugars at times and have a tendency to run high when under duress
(yay), so the idea of a CGM to help keep me and my future child safe while he or she incubates inside of me sounds like a necessary safety measure for both me and my baby-to-be.
So ... I'm on the long road towards CGM insurance coverage. I will show these insurance reps that diabetics have every right to the tools available to manage their disease. Cover me now, and I'll achieve tighter control. My blood sugars will be more closely monitored and managed. The risk of debilitating diabetes complications can be reduced. My life may be improved, just as an insulin pump improved my control. I may live longer, for crying out loud. That's a plus, right? I tend to think so, and I'd venture to say that my family agrees.
I know insurance carriers don't care if I'm happy. They don't care about my children or my husband or my mother. They care about their bottom line. Well how about this: Make the investment in me now and I will be healthier.
It costs less to manage diabetes than it does to manage diabetes complications.