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The Long Road Towards Insurance Coverage.

Pay to keep me healthy?  Or pay when I am sick?  Your call.(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."

She laughed.

"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. 

"Hi Kerri,
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%.

Thanks,

(Dexcom Guy)"

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.

Comments

Hi Kerri -

When I got my Dexcom, they sent me a canned letter of medical necessity. If you'd like, I can forward you my copy, or you should be able to get one directly from them that has your info on it. Good luck with all this - it's disgusting how much of a struggle it is to get the care we need.

Jenni

Jenni - Thanks! But Dexcom did send me the LOMN boilerplate. I just plan on tweaking the hell out of it. :) Did you ever get your CGM covered?

Kerri- Check out the Children with Diabetes website, on the forums there is a whole thread about insurance and CGMS. Also there is a guy named Rick that really knows his stuff.
-Trish
ps see you in Florida!

We really shouldn't have to jump through hoops like this to get the newest technology available. It's so discouraging. I read on another blog the other day (can't remember which one) that Blue Cross is also starting to deny coverage for the same reasons - so-called lack of clinical evidence. I have Blue Cross and was excited to talk to my endo about getting a CGM at my next appointment. Granted, I'll still bring it up, but it's frustrating to go in knowing we will probably have a big fight ahead of us - and one we may not win.

Hey, Kerri. We're jumping through the same hoops as you right now. We recently posted a thread on DD tracking insurance companies that are okaying CGMSes with little to know resistance. I hope you can get it approved. With a little luck, the insurance folks will find this blog and okay it just to get some positive press. :)
http://www.diabetesdaily.com/forum/continuous-glucose-monitors-cgms/15757-insurance-covers-medtronic-minimed-continuous-glucose-monitoring-system

Kerri-
Good luck trying! I jumped through hoops with Medtronic and my insurance company for 4 months (3 of which I was pregnant during) before they told me that my insurance company won't cover the CGMS. I am now paying out of pocket for my sensors which are damn expensive but so worth it! I'm in the letter writing process and being pregnant you would think that they would want to cover me. Nope! Best of luck to you!

Amen sister! I am currently trying to convince my insurance company of the very same thing! They are trying to stop paying for my sensors for my MiniMed CGMS.
It's such a horrible thing that they won't pay to keep me from having lows that I might not wake up from. Or a high that might put me in the hospital.
Sigh.

Have you tried calling your insurance company and asking for the supervisor? We never speak to a customer rep from our insurance company. And we pretty much get things covered that the reps say aren't covered.

The CGMS is costly, but keep trying. You never know if you'll get a sympathetic insurance supervisor on the line.

i'm hopping mad at Blue Shield today, since I just found out that when my company renewed their contract in May, coverage for a new insulin pump and supplies (my warranty is up in November) dropped to 50%, after deductible. And this is for PPO. Ouch...! there goes at least $4000 out of pocket. With the costs and insurance company battles, I really need to determine whether CGMS would be worth it when I upgrade to the 522.

I agree though, that you can't place a cost on health. I'd rather manage my diabetes well with expensive technology and enjoy a long healthy life, than go back to injections with an A1C of 9% =b

Hi Kerri - I love your site (but have never commented) - I felt the need to comment after this post. I just had a baby seven months ago. My insurance - BCBS - would not cover a CGMS even after I had a letter from my high risk doctor. I spent my entire pregnancy testing and changing out infusion sets. I had no problems at all. But it was still scary and I was on edge for the entire pregnancy.

My advice is that you do exactly what are you doing - start now. Otherwise, you will be dealing with a pregnancy while dealing with getting a CGMS. It's a lot of stress on the body, you know?

Good luck!

Yeah - this is why my 10 year old doesn't have one :

Totally different situation, but similar logic - cover birth control for women who want it so you don't have to cover medical expenses from unexpected pregnancies. It's far more expensive for a hospital birth than it is for years of birth control. So simple.

Kerri,

Our insurance company covers the CGM without question now, but it wasn't always that way. What I did to convince them at first was I spoke their language...money. I made a spreadsheet showing how much they were spending on test strips versus how much they would spend for a CGM. The math always worked out where they would come out ahead. Give it a go.

Please just cover it so that her mother can have a good nights sleep!! I love her!

We spent a year trying to get coverage for my son, who just turned 4. It was a long battle & we were turned down on numerous appeals. Finally our last chance was an outside company who reviewed the insurance company's decision & it was overturned - WAHOO!! It was overturned based on his hypoglycemic unawareness. He had gotten down to 24 at preschool with no symptoms & I think that was the evidence they needed. Hopefully it will get easier as more people "fight the good fight!" Best of luck with your battle!

Did I read right that you haven't heard of DME before? Wasn't your pump covered as a DME? What I ran into when I got my new pump was that there was a DME cap of $3500. I fought them a little and they got the cap removed for me for as long as I am with my current insurance. CGMS - that is a different frustrating story.

I think Oxford means no charge after your deductible and coinsurance are met, with your deductible being $1000 and your coinsurance 30%.

Hi Kerri,
Very recently I was successful in getting "coverage" for my insulin pump and CGMS (minimed). I am a Type Other so it took quite a fight. My doctor sent in 18 pages of documentation and I sent in a personal letter. What I believe worked was I spoke in terms of money. It took two appeals, but they agreed that it was medically necessary.

BUT... although they "approved" both pieces of equipment, insurance doesn't want to put a pretty penny towards them and getting the bills has become my next fight.

Out of control diabetes takes a toll on my other health problems and I used that "proof" to prove my case. Hospitalizing me for complications would be much more expensive than the pump and CGMS. Here is my letter I sent in to the insurance. Not sure if you could use any of it, but I thought I would post it anyway.
my personal letter
Sara, how on earth did you get your DME cap removed??? I am about to max out my lifetime limit and would love your advice!

I did with my old insurance. I recently switched jobs and so I'm going through the motions again with the new insurance. It's looking like they'll cover some portion of it, but I have no idea how much just yet.

Having type 1 diabetes dictates entitlement to the latest tools in diabetes management as they are developed. Not in the future but now. But the truth of the matter is type 2 diabetes(they got the numbers) dictates how insurance company pays.
Mark

It sure would be a lot easier for everyone if you all (pronounced "y'all" in Texas) were to share your detailed info within a tools framework rather than random comments on multiple websites and newsgroups. A free resource on the web supporting reimbursement can be found at http://cgmscentral.com Go ahead and try it ;)

You might see if this info is helpful regarding Oxford Health Plans posted by a user at CGMSCENTRAL.COM:

http://www.cgmscentral.com/node/66

Like everyone else I too am going through the CGM dance with my insurance company. Good luck to us all.

My frustration has not been with my insurance, but with the Dexcom insurance department. My insurance would not cover the receiver cost, but will pay 70% of the sensors. I first went on Dex in Dec. and promptly received a check from my insurance. However, I have not received one since, despite placing four orders, due to Dex not filing. I know they had some turnover in the dept., but I only received a response after telling them I can't afford to order any more sensors until I get some money from my insurance. That did get a response, and they now say they've filed, so I'm hoping to see the results soon. With the growing popularity of the cgm, they need to make sure they get their act together.

As a clarification to my previous post, cgmscentral.com is a free resource (non-commercial) on the web for the patient community dedicated to helping secure reimbursement for the new continuous glucose monitoring systems. The tools on this site are a spin-off from our research efforts in the field of diabetes by Diabetech (http://diabetech.net), a company I founded following my daughter's diagnosis with type 1 diabetes in 2001. I hope you find it helpful.

Kerri..I just got turned down again for the dexcom....and i keep trying to get ahold of thema and ask them how much it will cost out of my own pocket, but i cant get a straight answer. Do you by chance know how much these things cost if my insurance wont help me?

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