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CGM Denial - Yes, Another One.

Battling for CGM coverage.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.  

Best,

Kerri Morrone Sparling

Comments

I don't really know what to say besides - wow.

Since I'm having some similar issues (I had the CGMS, but then they revoked my coverage and I'm having to fight them to start paying for sensors again), I'm in awe of your ability to be civil. I think I would've had to rewrite the letter multiple times to extract the curses and bitter sarcasm I would have inserted on my first draft.

Here's to an external appeal! I hope you get your $25 worth :)

Kerri -
UNBELIEVABLE. Continue to give fight for your CGMS and give them hell, while taking the highroad with grace and dignity.
This is probably a stupid question to ask, but could you to take Oxford to court like Scott S is considering doing with Caremark? He's fighting for his supplies, not a CGMS. Just a thought.
k2

How frustrating.

Unbelievable!!! When will the insurance companies pull their heads out of their butts and realize we are not asking for the world. Just for something that will help us stay as healthy as we can. I'm sending you a big hug and many cheers as you continue to fight.

When will they learn???

Keep fighting, K.

Reading between the lines here lies(no pun intended) their caveat:"This type of continuous glucose monitoring has not been shown to provide superior health outcomes." They are saying the meter works as well as the cgms. And it does of course, if you are willing to check your blood sugar every 5 minutes
but here in lies(the truth and nothing but the truth,so help me God)the real caveat, a person cannot practically do that. The truth of the matter is that cgms would help the person tremendously achieve more normal blood sugars. This is all about the money and sadly has nothing to do about better control, better a1c's fewer hypo's. One who does not have to inject their own insulin will turn a blind eye when it comes down to the practicality vs the dollars and no sense.
Mark

Wow... I can't believe this.

Oh no!! When will the insurance companies EVER understand!? I just don't get it. We just switched to Oxford (NJ) Insurance, and we are going to start the battle for a cgms, and this makes me nervous about it. I'm only 17 though, so my mom will take care of most of it, because they won't talk to me yet...but, I want to wish you good luck! Keep hounding them until they can't take it anymore and approve it just so you dont bother them!! :P Lol!!

Good Luck Kerri!!

Malyssa =)

"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."

May I ask, why the **** has a general surgeon been placed in a position to determine medical necessity for a device prescribed by an endocrinologist?

You may be able to request an additional appeal on that basis. You could request that the case be reviewed by an endocrinologist (or an internist). Regardless of how good a doctor that guy is, he has no training or background to make a decision on the medical necessity of this device. You wouldn't ask an internist to decided upon the necessity of a particular surgical procedure, why should a surgeon determine the appropriateness in this case?

Keep fighting, Kerri! My insurance plan pays for my sensors @ 100%! So it is possible to get them covered. :) And it DOES make BG management much better--not perfect, but much better.

I'm wondering if they were trying to impress you with the fact that a "medical director with a specialty in General Surgery" has denied you or if they were trying to elicit giggles? Maybe ask next time for a review by a qualified doctor with a specialty in oh...say... endocrinology.

I truly feel for you in your battle here and wish I was your CM at your insurance company....I'd make sure to get it taken care of for you! I feel victorious knowing that I've gotten them covered for my patients that have requested them...including one new mom who is breastfeeding! Anyway, good luck to you and hopefully the external review will be successful. It doesn't really sound like Oxford has taken your request seriously since they had a General Surgeon, and not an endo, review your request. I mean, what the heck does a General Surgeon know (aside from the basics) about CGMS???

Anyway, good luck to you! I'll be sending all of my positive thoughts your way!!!

Keep fighting the fight Kerri.

You are an inspiration.

Kerri,

You know I totally get your frustration, because I've been there too. My own battle for coverage may have bee slightly different, but the one thing I do know is that you can't give up - even if it takes two years.

One of the key pieces of evidence I had when I eventually clinched it a couple of months back was records of my blood glucose levels both on and off sensor. These were simple Excel charts and graphs but clearly showed higher highs, lower lows and greater swings and variance when I was off sensor. A graphical display of what happens to your blood sugars can tell a thousand words. The point is that large scale studies may not be showing benefits ("superior health outcomes") from CGM for everyone - but your numbers can prove it is beneficial to YOU.

I can't believe they charge you $25 to continue the appeal.

Good Luck!

I hope it works out!

Will they ever learn? I wonder if they would supply enough strips for you to test every 5 minutes???? How much would that cost?? Let us see, 12 x 24 = 288. Inexpensive strips cost $.50. That is $144 per day!!!

I LOVE that you are posting these.

Thank you.

Kerri,

I just heard from my doc yesterday that BCBS is supposed to have a meeting in September to discuss coverage of CGMS. Have you heard anything about this?

What a bunch of hypocrites!

Thank you for fighting this battle, for yourself, and in a way, on behalf of all of us out there.

I just saw Oprah yesterday and it was on Michael Moore's movie "sIcko" and it just enraged me yet again...how insurance companies are designed to PROFIT from illness and how the only way to PROFIT is to DENY CLAIMS of people who need coverage.

We need a new system.
I hope Obama or whomever wins as president can help.

I'm not holding my breath, but WE MUST KEEP FIGHTING.

Amazing you have to pay those hooligans $25 for an appeal, though! Crimeny!!

Unbelievable!
(and yet it isn't)

Keep fighting! You are paving the road for future type 1 diabetics to have coverage, and that is so important. Good luck with the outside appeal.

Ugh, Makes me sick to my stomach. Please everyone sign the CGM Anti-Denial Petition http://www.ipetitions.com/petition/CGMSdenial/

gina

they're WHACKED!

i think i need to come furminate that medical director with a specialty in General Surgery

Keep fighting. Their reason for a refusal is ridiculous. And they say it comes from a medical director who is a specialist in general surgery. Well no wonder they keep refusing. They are not using a specialist in Diabetes Care. You go girl.

This is a note to Jacque, I have heard this as I am a BCBS of TN client. I was approved for CGMS in February and have dropped by a1c drastically, but they are saying they may quit covering the sensors. That's what the meeting is supposed to be about.

You just gotta switch off of oxford. I just switched, and once I did my doctor admitted to me that she didn't think I had any chance of getting coverage under oxford. Simple, huh?

Your letter was amazingly well written. Good luck with your appeal. I hope for your sake that oxford gets real on this issue.

Btw, do they send you all the junk pamphlets about how dieting might be able to get me off of insulin that they used to send me? LOL

I share your frustration and recieved a similar denial. I have been paying for the CGMS myself for the past 2 years I sent copies of 2 months of BG's before and after. I had 110 BG's over 200,5 BG's over 300 and 5 under 60 for the 2 months prior to using the CGMS. After it was reduced to 62 BG's above 200, 2 above 300 and none below 60. This is based on meter testing about 8 times a day. So even though it reduced my high & low episodes in half they still maintain it does not help my control. Their reasoning is that I needed to have frequent BG's below 50! I explained that I do feel low's below 50 and do not bother to test at these levels, since I feel like I'm about to pass out! I feel much more in control and can't imagine not having the CGMS, I hope they will re-examine the criteria. Keep fighting!

Maybe you should move to Minnesota? :) I have Blue Cross BS of MN, and I got the Minimed CGM last year. I really hated it, so I'm going to try the Dexcom one now.

What a PITA!

I didn't do this battle over a CGM, but I did the same battle over an ECHO ultrasound when I was pregnant with my first child. And you know what finally worked? It was basically a simple letter that detailed the costs of care of a seriously premature infant if preventative medicine was not approved--like:

1 Hour NICU time for continuous neonatal heart monitoring = $90,000

Neonatal Heart surgery = $XXXXX

Neonatal anaesthesiology = $XXXXX

on and on and on, detailing all the complications/costs from congenital heart defects--and then one line that detailed the cost of the proceedure needed and a pithy little closing that referenced the cost I was asking them to pay vs the cost they were more interested in paying, and how I was really just concerned for their bottom line and maintaining low premiums for the other subscribers.

I don't know if that's what actually worked, but four years later, I've still not received a bill for that ECHO. :) At the time, we had United for our insurance company, and they're the parent company of Oxford.

Kerri -

If you need more backup material, here is a link to Anthem's document that defines their criteria for CGM approval:

http://www.anthem.com/medicalpolicies/policies/mp_pw_a049550.htm

Aetna's policy is also on the net:

http://www.aetna.com/cpb/medical/data/1_99/0070.html

Good Luck!

Edgepark Medical is processing CGM for pts with Oxford now.

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