« Kiss Diabetes Goodbye! | Main | It's Friday. That Means ... »

When At First You Aren't Approved - Appeal, Appeal, Appeal.

There's a lot of buzz in the blogosphere today about insurance denials and appeals, starting with an article in the Wall Street Journal about "Pushing Back When Insurers Deny Coverage For Treatment."  Scott Strumello brought this article to my attention this morning via his comprehensive blog post about it, and Bernard sent me there again with his perspective.  And after reading everyone's take, in addition to having experienced three denials for CGM coverage from my insurance company (Oxford Health), I realize that I have gone at this problem the wrong way.

Insurance companies don't care about my future baby.  They don't care about my A1c.  Unfortunately, insurance companies are watching dollars and cents, not good sense.  A passionate letter from a patient doesn't even come close to moving an insurance company to provide coverage or overturn an appeal.  They seem to respond to "the facts" only, and I should have attacked them with facts to begin with.  Instead, I took the personal approach, which left me denied three times.  And it's partially my fault because I expect them to care, even when I know they won't.  My approach was arrogant, thinking they'd respond to actual emotion.

But this time?  No emotion at all.  This appeal was just the facts, ma'am.

I sent the Connecticut Department of Insurance a packet of information this morning, in hopes of having my Dexcom CGM system denial overturned.   I included the following:

  • Request for External Appeal form (my insurance information, healthcare provider information, detailed description of disagreement with healthcare plan)
  • The denial letter from Oxford Health Plans, stating that their decision is final
  • Proof that the service in question is a covered benefit (this was in the form of my insurance policy benefit handbook)
  • Executed medical release form
  • Photocopy of my insurance card
  • Documentation supporting my appeal, including a letter from me, my endocrinologist, and Dexcom
  • Oh, and a check for $25.  They specify that this is non-refundable. 
Insurance appeal packet - heavy.

Under the guidance of the Region Managed Care Director at Dexcom, the supporting documentation I included was very factual and devoid of almost any emotion.  My personal letter, which was written with the help of the Dexcom rep and is so stoic and so dry that it doesn't even sound close to anything I would say is supposedly an example of what "will work."  The letter from my endocrinologist cited my elevated A1c, the ADA A1c standard for pregnancy, the Factor V issue, 22 years of IDDM, and various complications I've experienced (including the cotton wool spot, high blood pressure, etc).

Dexcom also provided a packet, which included the recent NEJM study results and other studies supporting the use of CGM technology to better control diabetes.  The letter from my Dexcom rep included a demonstration of the proven benefits of CGM technology on health outcomes, and also outlined the appeal-denied-appeal-denied cycle that I've been in for the last few months.

So it's in the FedEx box now and waiting to be sent off to the Connecticut Department of Insurance.  Each item is tabbed and in the order requested by the appeal form.  It's on time, comprehensive, and fact-filled.  I hope this appeal gets my CGM approved.

The only frustrating part of this process was that I couldn't really lash out.  I couldn't tell these insurance companies what I was really thinking, which was along the lines of "WHAT THE FUCK IS WRONG WITH YOU?  CAN'T YOU SEE THAT THIS TECHNOLOGY WORKS AND I WANT A HEALTHY PREGNANCY AND WHO ARE YOU TO TELL ME I'M NOT APPROVED?!!"  (Ahem.  Sorry.)  It's infuriating to play by their rules, but I'll do whatever it takes to obtain approval.  It makes me absolutely crazy that this technology exists and it has worked for me and it's still not covered.  Don't insurance companies want people to remain healthy?  Isn't there a cost-benefit to them for acting proactively instead of reactively? What is wrong with this healthcare system?!

I'll wait patiently.  I'll hope that this fact-driven approach gets me somewhere.  And I'm very thankful for the assistance and support I've received from Dexcom, dLife, and my friends and family.

But I had to get my digs in somewhere - the memo line of the check is "ridiculous fee for appeal."  Jerkface insurance company.  They're messing with the wrong girl.

(I hope.) 

Comments

I'm sorry I missed your previous posts on this appeal or I would have told you this sooner. I'm not a diabetic, but I've struggled with inane insurance issues on other subjects that were deemed 'not medically necessary'--something that just about the entire public is going to face soon w/o some kind of regulation from the FDA/gov't to rein in these actuarial bastards. Insurance is an industry of RISK, and as such, needs to accept RISK as part of the cost of doing business; these a-holes want to change the rules and remove their RISK, denying all so that their playing field becomes PURE PROFIT if left unchecked. OK, I'll stop ranting, this is your blog. ;)

My point is, you did the right thing by being dispassionate, that's step #1. You presented your medical facts that support your case, step #2. Step #3, which hopefully won't be needed is to present a case to the cost of your insurance company of how much they will pay in a worst-case scenario if you were to get pregnant, suffer an injury, etc. should your glucose not be well-controlled. Make the case dispassionately that it is their FINANCIAL BEST INTEREST to cover it given your history and how much it will cost them if they don't.

Good luck!

Sounds like a winning package to me!

It's a shame that these companies are just in business to make money, and that denials are a common strategy to get people to give up. Makes all that warm, fuzzy corporate image advertising about caring ring hollow, doesn't it?

Best to stick to the cold, factual letters that get results in this case. Good luck!

As always, I am rooting for you!

Kerri

Thanks for the callout and I hope that your appeal works and quickly.

The annoying thing in my mind is that if my control was worse and I was using Glucagon or having an ambulance ride every month or so I think it would be a good deal easier to get coverage. But since my control is reasonably good (thanks to the Dexcom) it's now harder to get coverage.

It makes me MAD.

Personally, I'd like to see a single-payer system instead of private insurance, but I doubt we'll never see it here, so we have this stuff instead. Hopefully, you will have success in navigating this non-sensical world!

Who knew that when dealing with a company who pays for people's health you had to act robotic and unfeeling. I hope this appeal appeals to those jerkfaces.

I hope this works for you. I've been using the Minimed CGMS since March (paid out-of-pocket, thanks Aetna), and I feel completely vulnerable without a sensor on. Like you, I've got baby on the brain (we're actively trying), and I will not take any chances.

I recently started a new job and have new insurance, so I'll be starting the "begging for CGMS coverage" process again soon. Like Bernard wrote, I'm concerned that my good A1c and lack of hypos will work against me.

Good luck!

i'm glad to see the memo line of the check. the package may be impersonal and so non-kerri. but I LOVED the memo line! that's my girl!

Kerri, I hope your appeal works this time. I work in medical billing and often write letters appealing things that insurance companies have denied for one reason or another. It's a pain, but facts are the way to go.

I'm crossing my fingers for you!

As always, I'm rooting for you on this! Every time I am surprised by an unusually high or low number on my meter, I don't understand why we are being denied this tool!!

Like tonight when I didn't realize I had a bad site until 3 hours after my meal when I was met by a number even higher than a bowling score!

I'm proud to be a member of your pep squad. GO KERRI!!!

oh Keri ,
we all have had this trial it is a pain trying to deal with these insane insurance companies . It is also the FDA as well and they stick their two cents in too . I still say socialized medicine would work here too but because of the FDA it wont be here . Our government claims it wont work here in the states . Well how does Canada and the UK make it work then ? I dont want to hear the bull from the FDA . It is because of the FDA that our insurance rates are so high as well . It would cost my husband and me 900.00 a month to put me on his employees insurance . I go without because we cannot afford to live paying 900.00 a month insurance . I just dont understand how the government can justify allowing insurance companies to turn us down when we help pay a million dollars for a screw on the space shuttle . crazy . good luck keri .

Pardon me as I momentarily de-lurk.

Kerri, I wish you all the luck in the world getting your CGMS approved.

I was moved to come out of hiding by Scott's comment regarding single payer insurance. As an American living in the UK I have to say the level and quality of service I received in the U.S. compared to that of the UK was far superior. This of course is just my personal experience, but the fact I have been forced to wait weeks for a procedure that I have had on the day prescribed in the U.S. is just the tip of the iceberg. Here I am forced to buy my own pump supplies (fortunately I already had the pump when I moved over here) as my control was too good to even be considered for one. The most recent statistics I've been able to find is that under the NHS only one in 1,000 type 1 diabetics are using an insulin pump compared to, I believe, 1 in six in the U.S.

I don't want to turn your blog into a debate over the merits of various insurance systems and there are clearly huge flaws in the American system, but we should careful what we wish for because it might turn out to be even worse.

Re-lurking...

I wish you the best of luck with this, Kerri. Any idea how long it will take for them to respond?

Kerri,
Excuse me, but what bullshit. I told you the same exaact thing when you wrote your very first emotional appeal on their decision to deny you coverage.
Is sixuntilme some kind of egoic trip you write to get groupies to blow smoke up your ass for any blog you deem right and true and just? Perhaps you ought to call Superman. Gawd, I hate diabetics. They are so fucking self absorbed.
I can't read or post on this crap anymore.
Mark
Do me a favor, delete this comment from being posted, I would hate to offend the groupies

Tools. All of them.

Hang in there. I have a feeling this one will do the trick.

Hi Kerri,

Here's an article for you in the Sept. 25 issue of the British Medical Journal:

Effectiveness of continuous glucose monitoring in pregnant women with diabetes: randomised clinical trial

http://www.bmj.com/cgi/content/full/337/sep25_2/a1680

Looking forward to good news re the professional appeal!

Give. Them. Hell.

I grew up in Canada and I can also state that standardized health care is not all it's cracked up to be.

There's huge trade offs either way. I have several diabetic friends in Canada, on never ending waiting lists to get pumps.

Mark,

I am really sorry if my post offended you or pissed you off. Not my intent. I actually was admitting that I completely screwed up the appeal process on my CGM stuff. And I remember your comment about giving them numbers in the first place, and how you mentioned that the cost of sensors is obscene. You were right. And I can take criticism, and I know that my opinions are just that - my opinions. But for you to leave that comment - I'm not sure what kind of a response you expected. This is my blog, and it's about my life and how diabetes plays in, so it is going to be about me and host my opinions. If my posts make you feel the need to leave vitriolic comments like these, stop reading.

Thanks for reading, and thanks for your comment on my original post. That one at least was productive. My best to you and your family - take care.

Sincerely,
Kerri.

Mark,
a personal blog, is just that, personal. And if you think we are so self absorbed as you say, don’t read. You are not demanded to read our blogs, or comment on them. As a matter of fact, I think we’d all rather you didn’t.

Now I’d love to say “FUCK OFF AND DIE!”, but, just seeing you humiliated by the posting of your asinine comment is good enough for me!

landileigh

@mark:
Not only do I think Kerri is a phenomenal human being that does not deserve the kind of remarks you are making. I think she does the diabetic community a GREAT service by sharing her experience.

Her blog is personal, which is what all people with diabetes are first: persons. So her personal experiences resonate with all her readers.

I am very sorry that you feel so strongly about diabetics. Now (like Landileigh said), if you hate diabetics, what are you doing reading Kerri's blog? There's plenty of space in the blogosphere where you can hang out if you so much hate us.

@mark

Dude seriously, why are you here? Do you have diabetes? If not take a hike, we don't need your assinine comments here. You need to get a life. Go lurk someone else and stop bothering Kerri. Idiot.

Hi Kerri, I am not diabetic, but my little boy who is 8 years old is Type 1. He was diagnosised just before his 5th Birthday three years ago. Tears rolled down my face reading your story, the comments of your appeal and the guy who wrote the cold hearted note using the word "Hate". My heart goes out to you for posting your personal thoughts/experiences and to those who support what you write and comment gracefully. Please don't give up on your APPEALS process. I use to work in Managed Care and helped Patients write letters to insurance companies. Our letters would come back approved. Insurance companies want you to "give up", but don't. You will finally get what you have been waiting for. God bless you and all that you do here on "Your Personal Site". Thank you for inviting me into read your comments. I look forward to reading all the good news to come. Rita

Hi, I have read you blog multiple times before I bought my dexcom 7. I had the mimimed and it broke, it was too expensive to replace. The dexcom 7 is cheaper. I am in the process of doing an appeal with my insurance company to have them refund me the money that was spent on the monitor. I was hoping you could help me out. Do you still have the appeal letter that ultimately got you approval? Would you be willing to share it? I have contacted Dexcom in the meantime. Thank you.

Hi Kerri, I'm glad to see that the insurance fight worked out for you. I'm working on the third appeal letter requesting a monitor and pump for my brother and I'm feeling quite discouraged. Not sure what I should say ….. Would you be willing to share your winning appeal letter with me? I’m so concerned about his health, he often experiences hypoglycemic unawareness…… and I know the CGMS would help.

Thanks.

I am looking to get a dexcom CGM i also have Oxford. I was going to ask my rendo to get me started on gettting one. Am i really going to get into a battle with my insurance company. I hasd ahuge problem already trying to get on the kidny/pancreas transplant list because they refused to cover a stress test for me needed to clear me for a transplant.

Post a comment

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