« Technology Is Fun! | Main | Slackin' A Bit. »

CGM: Denied Once Again.

Please approve my CGM!Dear Insurance Company,

I got your letter yesterday.  I opened it up and saw your second denial.

"Our Medical Director has decided to uphold the initial adverse determination because this monitoring system has not been proven to be any more effective in the management of diabetes mellitus than the standard monitoring."

I disagree.

I test my blood sugar 15 times per day.  I test when I wake up, before I eat, after I eat, before I exercise, while I exercise, before I sleep, and sometimes in the middle of the night.  I also test when I feel "off."  I try to catch the fluctuations as often as I can and I respond accordingly.  Unfortunately, I am only seeing snapshots with this "standard monitoring," instead of the streaming video I get from a CGM.  Maintaining tight control is difficult with only snapshots of information.

I got married two months ago and my husband and I are planning to start a family in the next year or so.  As a type 1 diabetic for over 21 years, preparing my body for baby is a bit of a daunting task.  My endocrinologist has told me to bring my A1C as close to 6% as possible.  I am starting the Pregnancy Clinic at Joslin at the end of the summer and am working hard to run my numbers tight.  Unfortunately, running at a tighter clip results in more low blood sugars. 

Sometimes I don't feel my low blood sugars.  I've felt perfectly fine and then tested to see a result of 38 mg/dl or 41 mg/dl or 45 mg/dl.  These are not safe numbers.  As a result of my efforts to lower my A1C, it takes longer for me to feel the lows.  I have hypoglycemic unawareness.  A CGM would keep me safer from these undetected lows.  And when I'm pregnant, it would protect me and my baby - at no extra cost to your company. 

And in January 2003, my then-boyfriend woke up to find me unresponsive and sweaty.  He tried to get me to drink juice but I fought him off.  The paramedics were called and it took three of them to hold me down and administer glucose.  After a tube of glucose gel, my blood sugar was 44 mg/dl.  Had my ex not woken up, discovered I was low, and called the paramedics, I may have died.  Let's just think about that for a minute, okay?  Dead, thanks to a low blood sugar that I did not wake up for.  A CGM would have warned me about my falling glucose with a loud and relentless BEEEEEEEP.  I would have woken up, tested, and most likely caught this low at 60 mg/dl instead of whatever low I achieved that morning.

While I believe that your company should respond to these issues on an empathetic and proactive level, you may only care about the financial aspects of this issue.  I offer the following:

The Dexcom unit I am using was given to me by the company.  You would not need to purchase the receiver unit or the transmitter at this time.  This is a savings of $1000.00.  What I am looking to cover is the cost of Dexcom sensors, which are $240 for four sensors.  Over the course of a year, these sensors would cost $2,880.

To offset this cost, I would be testing less frequently.  I would go from testing 15 times a day to approximately 7 times, saving $5.00 a day.  Over the course of a year, I would be using 2,920 less test strips.  With test strips costing approximately $1.00 apiece, this would be a savings of $2,920 per year. ... Wait a minute, that's saving more than the sensors are costing.  Looks like you guys just made $40, not to mention co-pays for these items! 

We should also factor in the cost of an ambulance ride, if I were to have another low that required assistance.  Medical intervention could cost upwards of $1,000.  The CGM is a measure that could prevent this cost from occurring.   

These are just the immediate cost savings to your company.  Never mind the savings that will accrue long-term, when my body remains healthy as a result of achieving a tight A1C instead of developing expensive diabetes-related complications.

Overall, it makes more financial sense to invest in a CGM for me.  Proactive measures will keep me from costing insurance companies large sums in the future, when more serious issues may arise as a result of several decades of diabetes.  

And, as an added bonus, I will be healthier.  Imagine that.

I am looking forward to your response.  

Sincerely,
Kerri Morrone Sparling 

Comments

Insurance misers give Motolano the RAGE!

Do you have a healthcare pro who can maybe call on your behalf? I was struggling with an issue with my coverage (they were only willing to pay for vials, and not quick pens of my basal), but my DSMT nurse called and bullied someone into covering the pens.

Ugh. Insurance companies are like the old FAA analogy: "Tombstone Agencies" Meaning they'll only take action AFTER an accident or something horrible happens.

And you're right on strips. On the weeks I DON'T use wear my CGM I can't believe how many I go through...

Wish you the best on this one.

p.s. You already are a family. Just of two right now.

See, here's where you maybe went slightly wrong. I LOVE this letter, but I think rather than threatening that you might die from low blood sugar (Insurance company CEO says "Yay! One less pricey chronically ill chick to cover!") I'd suggest you use the word COMA. Use it two or three times, if possible. Coma means millions of dollars to them. Death means a savings of hundreds of thousands. Keeping in mind that they have hearts one step less sympathetic than leeches, which do you think scares them more?

I'd stress the hypo unawareness, since in most cases that's the only way they'll consider coverage. Mostly because the similarly leech-like risk statisticians have warned them about the priciness of that COMA.

Awesome letter, though. Wishing you the best of luck.

Andrew - That's a good idea, having someone who is familiar with the health insurance "jargon" to call on my behalf. I'll see who I can drum up.

James - I agree completely. Insurance companies are reactive instead of proactive. The American healthcare system is the same way. Preventative measures? They can't wrap their heads around the concept.

And you're right: I am a family of two. :)

Elizabeth - Excellent point. I'm faxing out this letter this afternoon, so I appreciate your feedback. I'll definitely make that change. It hits them where it hurts them the most: their bottom line.

the response from your insurance is so infuriating. If it were me I don't know if I'd cry or just be full of rage or some confused mixture. Your response letter is good. Don't give in. Maybe you could actually document in a chart the # of times you test on days w/Dexcom vs days without to prove your point.

My insurance finally is paying for my REAL time system, but that was after three appeals. I honestly think they finally agreed to pay to get rid of me. The next step would have been an appeal in person in front of a committee and I'm sure they wanted to avoid that. So...keep appealing! It's so absurd we have to jump through these hoops in the first place though. Just infuriating.

I also used the "I'll go through less test strips with CGM" rationale in one of my letters. But, turns out that I still test 15 times a day even with CGM since I am pregnant. But I'm sure I'll cut that back once this babe is out! My fingers look like swiss cheese. Ouch.

Good luck Kerri! Just keep hassling those insurance you-know-whats.

Keep fighting. I think they always say no as long as they can. There is no reason they should not cover it. It will make you healthier, which in turn cost them less money. Morons.

The insurance companies say they want "evidence" that CGMS improves outcomes -- evidence from clinical controlled trials is great but it is really hard to wait when you are living with diabetes NOW.

Love the part where you start crunching the numbers for them and show them the immediate savings on the test strips. I hope that makes them take notice and send you a long waited APPROVAL!!!

I like Elizabeth's suggestion. Go get 'em, Coma Girl.

Hello,

Is your insurance coverage through your work or your hubby's?? Because if it through your company I would enlist help from the HR department being that dLife is all about being diabetic and healthy. To have an insurance company that will not cover items such as CGMS seems to be totally backwards especially since there are several insurance companies that will cover CGMS with ZERO appeals such as United Health care. Just my thought for what it is worth. Good luck--Dave

can't help but wonder if their 'medical director' has diabetes. perhaps that's a question you should ask them/him/her in your reply.

after all, if the director is going to deny your claim bc "this monitoring system has not been proven to be any more effective in the management of diabetes mellitus than the standard monitoring" than the director better damn well have diabetes, otherwise how the hell would he/she know what works best?

Hey Kerri,
has anyone done a survey to investigate whether or not the insurance companies or even one company is manipulating the insurance market by denying most of the requests for CGMs?

We've read other blogs where people are saying I was denied too..I'm just wondering how many people have been denied, what their reasons for denial were, and who the companies are? Is there one in particular? or maybe a few...maybe they're working together. Maybe certain regions are being denied more often than others. But it doesn't make sense for an insurance company to deny approval when you can illustrate that it is really cost effective.

My doctor is just filling out the paperwork for me for the Dexcom, I'll let you know how it goes.

I think this is something that maybe all of the bloggers could unite on, and maybe include JDRF's round table, and see if over the next few months, we can get the names of diabetics who have been denied along with their insurance companies, and see if there is a pattern. If each of us bloggers puts up the question, has your insurance compnay denied your approval of a CGM? If so, please comment with the name of your insurance company and the reasons.
Because if we can get this information, we can get it to a number of very interesting people on Capital Hill......

Kerri, perhaps you could ask them to do something similar to the trial you had with one of your co-workers. have them be a diabetic for a day. Constant testing, all paid for out of pocket. Then have them wear a CGM for a day.

I am looking forward to their response as well. :)

First thing that popped in my head was what Elizabeth said, they would love us all dead.

Another pumper friend of mine has been using the CGM for two years and went through the whole appeal process including a phone conference with the MD at the insurance company and now just today he found out that his latest batch of sensors are denied because the coding has been changed for the CGM and they told him they are no longer covering the CGM for him as that appeal only applies to the old coding, WTF. He was irate and told me he is calling the local news, and going through his HR person in the morning.

Same insurance company and now another denial after already approving through a long appeal process because of CODING changes, (shaking my head) :(

Amen, amen. That's one of the most finely-crafted GFY letters I've ever read. (Call me if you don't understand the acronym.) I really hope they wise up and do what's best for them - and you.

These insurance companies make almost no sense to me. The letter is great, I hope it resonates with someone there.

Good luck!

Awesome, awesome letter!!! I wish you luck with this issue and hope that the insurance company opens their eyes and approves the CGMS for you. I just don't get why they don't see the need for these ... it infuriates me.

This is just another infuriating reminder that insurance is not about health, but rather about the insurance executives' money. Kerri, I believe you will get your CGM at the end of the (very long) day due to your persistence and intelligent case-making. but what an ordeal to have to endure. I'm cheering for you.

I'm curious about which insurance company you are (not adequately) covered by. Is there a reason you don't mention the company who is treating you so badly (or maybe I missed it)? They HATE bad publicity and don't care for attention being focussed on their immoral failures. Although all insurance companies are more or less the same (because they are profit motivated - a natural conflict of interest), why not mention the one who is denying you? I have Oxford and haven't yet put in for a CGM, but I do know they make very frequent mistakes in reimbursing me for claims, always claiming the computer made a mistake. I think they systematically reject claims, hoping the claimee won't call to appeal (my last call took 25 minutes to sort it out and now I have to wait a month to see if they will give me reimbursement as they "look" at the claim again). I am convinced this is yet another way they try to save money. How tenatious will the patient be, or will the company win again? Of course, when one is deathly ill, one's ability to deal with insurance companies dimishes. Even when you're healthy, it's difficult, as you are finding. I think the people who work for these companies are as bad as any terrorist and our homeland security is at great risk by their underhanded nasty tactics and our country's total inability to responsibly deal with health care. BTW, Act-up is launching a campaign to get health care out of the hands of private, for profit insurance companies who have a vested interest in not covering costs - especially important for us chronics.

Thanks Kerri for your writing and fighting. Wishing you much GOOD LUCK. How stupid that you have to commit so much energy to THIS! It's really #@%Ked UP!

OH! so it is Oxford. Sorry I missed that from an earlier post. OH how I hate them!

I think I just sent you a spreadsheet that I used to get approval back before United Health Care was covering everyone for the CGM. I'm sure I've sent it before, but here goes anyway.

Great letter Kerri. Round three has begun! ding ding!

My Medtronic rep called me two weeks ago to tell me Aetna had signed a contract and approved the CGM for coverage.

My pump's warranty expires on July 21st, so I can order a CGM-compatible one then. When I do, I'll be ordering the CGM, too!!

Other companies will follow suit soon.

Great letter. Hope it works.

That is so frustrating and maddening that they denied it again.

Does anyone know which companies have/do cover thus far and which do not? Anyone have a list of this info anywhere? We may be going on Cigna soon and I'm wondering.... It'd be great if we could compile a list if it doesn't already exist.

Go get 'em! I bought the CGM for my son after I was denied. What am amazing tool!!! I have heard that Anthem is covering them if you can show that you test at least 8 times per day. I am with Humana and they have an auto deny policy.

We all just have to keep fighting. Remember there was a time when they wouldn't cover pumps too.

Good luck!!

I live in NYC too. I am awaiting my eternal third party appeal. I am not holding my breath!
Amy

I meant "external" although it does seem a bit eternal too.

I have Health Net or "Hell Net."
Kerri, you only have a certain amount of time from the insurance company appeal to send your packet to NYS Board of Insurance for an external review. If you miss it, you have no recourse.

AAARRRGHHH!!!! RAGE!!!! Reading this I wanted , "F**K YOU!' and other not nice words. I agree with Elizabeth. Coma sounds a lot worse than death to a bean counter.

I won my new york state board of insurance external appeal today!!!! That's a big GFY to my insurance company!!!!!!!

Post a comment

(All comments are moderated. Thanks for your patience!)