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.
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.