CGM Denial - Yes, Another One.
Dear Liana Masone, Grievance Associate at Oxford Health,
What can I do to help you understand why my request for a continuous glucose monitor should be approved? I've received your third and final letter, and according to your team:
"We have thoroughly considered all of the available information submitted in support of your appeal. Based upon review of that information and the terms of your plan, a medical director with a specialty in General Surgery, continues to uphold the denial of coverage for the Dexcom sensors. This type of continuous glucose monitoring has not been shown to provide superior health outcomes. Therefore, an Oxford medical diretor has determined that coverage for the Dexcom sensors is Not Medically Necessary, as the term is defined in your Certificate of Coverage."
You know what's great? The part of your website that talks about the 2008 Healthy Bonus Offers, claiming the following: "We recognize there are ways we can help members reduce out-of-pocket health are costs. We believe in the power of prevention: that is by taking a little extra time to eat better, exercise and reduce stress, individuals can do a better job of staying on the path of wellness."
Is that so? By seeking approval for the Dexcom continuous glucose monitoring device, I am trying to stop as many of the fluctuations in my blood sugar control as I can. I am also trying to safeguard my body against hypoglycemic unawareness, because my body does not recognize the symptoms of low blood sugar with any reliability. I am also preparing for pregnancy and making these CGM efforts for my baby and my husband. Proactive approach, no? You would do well to be more proactive in preventing complications, instead of being reactive and paying for them later.
According to the paperwork you sent me, I have been advised that I have exhausted my internal appeals and may now file an external appeal for CGM coverage. You have also told me that I need to enclose a check in the amount of $25.00 made out to the Treasurer, State of Connecticut. This check is the first item on your appeal application checklist, showing me how committed you are to making this appeal process as difficult as possible.
I have been a type 1 diabetic for almost 22 years. The paramedics have visited my home due to morning hypoglycemia. My A1c is currently above 7.5% and not within the range for pre-conception, as advised by my endocrinologist at Joslin. I do not want to experience diabetes-related complications, and I am trying to stay as healthy as I can. I will continue to fight for approval of a CGM.
In the next week, your team will receive a letter from my endocrinologist, stating her recommendation for CGM coverage. You will also receive my current blood work results, a copy of my certificate of coverage, and yes, my check for $25.00.
I look forward to your response.
Kerri Morrone Sparling