Getting CGMS Coverage

[Tonya]

Thought I would give a tid bit of info for the state of California-

If you doctor has written a letter of necessity, and you can show poor blood glucose control, you can appeal the insurance's decision through the California Board of Insurance. They have almost an 80% decision turn over rate for type ones at least.

Make sure you have written documentation, denial letters, records of blood sugars, etc.

Here is their link:

http://www.insurance.ca.gov/contact-us/0200-file-complaint/

Here is Aetnas policy:
CPB 0070 part VIII:

"Continuous Glucose Monitoring Devices :

Aetna considers continuous glucose monitoring devices (e.g., MiniMed Continuous Glucose Monitoring System, Guardian Real-Time Continuous Glucose Monitoring System, and the DexCom STS), which are used to continuously monitor diabetic persons' blood glucose levels over a three-day (72-hour) period, medically necessary for persons with type 1 diabetes who have either of the following problems in controlling blood glucose level, unresponsive to conventional insulin dose adjustment:

1. repeated hypo- and hyperglycemia at the same time each day; or
2. hypoglycemia unawareness.

No more than two CGMS monitoring periods are considered medically necessary within a 12-month period.
Aetna considers the long-term use of continuous glucose monitoring devices medically necessary as an adjunct to fingerstick testing of blood glucose in persons with type 1 diabetes who have had recurrent episodes of severe hypoglycemia (blood glucose less than 50mg/dL) despite appropriate modifications in insulin regimen and compliance with frequent self-monitoring (at least four fingersticks per day). Long-term use of continuous glucose monitoring devices are considered experimental and investigational for all other indications."

[Gina Capone]

Tonya, if you can post up that information up in this forum that would be great information to have. You can edit your discussion by clicking on your admin where it says EDIT this discussion.

[Phil Lerner]

The problem is, what if you have good control? In RI I was denied because my control was too good. (A1C = 6.4) Am I supposed to eat like a pig for a few months to get it up to 9 and suffer the consequences? The insurance companies refuse to acknowledge that long term they will save money by reimbursing for CGM's now, but I guess we've all heard that before.

[Gina Capone]

DAMNED IF YOU DO DAMNED IF YOU DON"T

Phillip Lerner said:

The problem is, what if you have good control? In RI I was denied because my control was too good. (A1C = 6.4) Am I supposed to eat like a pig for a few months to get it up to 9 and suffer the consequences? The insurance companies refuse to acknowledge that long term they will save money by reimbursing for CGM's now, but I guess we've all heard that before.

[Tonya]

To put it plainly: I have an A1C of 6.2. BUT I can still show that my blood sugar will be 288, and then fly down to 60. I take my blood sugar 10x a day- religiously -to prove this. You have to have your ducks in a row. You have to have documentation. I have seen some people who take their blood sugars 2x a day and claim they can't control their blood sugars. By not arming yourself with as much information as possible, you are bringing a twig to a gunfight. If you are going to take your fight to the state of California Insurance Board- make DARN sure you can show WHY you need it. (this isn't directed at anyone- I am just already fighting with Aetna, and know what they will ask and try to play on you)

[Sarah Elizabeth]

Phil, I completley sympathize. I havent even tried to get coverage. I know id be straight up denied because my control is" too good". HA what they dont get is I am testing my blood sugar 15xs a day and have the butchered finger tips to prove it.

My doctor doesnt even want me to go on the pump because he thinks I am doing fine. Let him try poking his fingers 15'xs a day and injecting so many times I cant recall to correct.

My control in the past wasnt always so good and I just found out I am spilling a small amount of protein in my urine. There is no way in hell I will allow myself to go out of control just to prove its a necessity. Though my goodness having a CGM would make it SO much easier for me.

Gina is right with her " damned if you do, damned if you dont" response.
Phil Lerner said:

The problem is, what if you have good control? In RI I was denied because my control was too good. (A1C = 6.4) Am I supposed to eat like a pig for a few months to get it up to 9 and suffer the consequences? The insurance companies refuse to acknowledge that long term they will save money by reimbursing for CGM's now, but I guess we've all heard that before.