Blue Cross and CGM's

[Phil Lerner]

BC will not pay for CGM's unless you can prove you have poor control. Even then they make it very difficult. They claim that CGM's are experimental. I have notes from my doctor and have included research but they refuse to budge. They claim my control is too good.

[Tonya]

You need to show the insurance companies continous high and lows. Document everything!

[Phil Lerner]

I did send them 500 test results over a 3 month period, but it made no difference. I believe they simply will not cover them.

[Conor]

I had the same problem with Blue Cross which by the way is the most expensive insurance offered by my employer.

About two years ago I had started having random lows, later followed by Hypoglycemia unawarness. With A1c levels below 7.0 they wouldn't even consider it. We worked with a case worker through our medical group and basically we were told at the time that the numbers wern't that bad to justify it. I guess a trip to the ER does not justify as being out of control.

[Denise Force]

Hi Phil,
I have Horizon BC/BS of NJ. Not sure if this is exactly the same as your plan, but I think most of the BC/BS plans are alike. I was approved for a CGM back in April of 2007, when Horizon was covering them. They decided to change their policy in 2008 and call them "investiagtional", as you know. I got a case manager through Horizon, and submitted my letter of medical necessity and my Carelink reports from the Medtronic website showing my frequent nightime hypos. My A1C is below 6, which is what they consider good control. After much back and forth between my case worker and the medical director, he decided to give approval for one month of sensors. He told the case worker that Horizon is revaluating their policy due to frequent customer appeals, and he thinks they may be covered within the next month. I am hoping this is the case as the sensor has been a wonderful thing for me. My advice is to keep trying and file the appeals if needed. The more they hear from us the easier it will get to get approval.

[Phil Lerner]

Hi Denise and Connor,

Thanks for your encouragement. I have appealed the decision all the way up the ladder. The next step is to sue them and by the time I pay the lawyer it would probably be cheaper to pay for it myself. I know someone who is very high up in the BC food chain who owes me a favor but apparently he was not that high up. However, I know someone who was on their board of directors and he said he would speak to other board members, after I had sent him copies of the research studies I found on this site. In addition I got the name of a state legislator who works on medical issues and I am in the process of writing a letter to her explaining what a CGM is and why it is necessary in the hope she would introduce legislation mandating coverage. I am assuming she knows nothing about diabetes and the need for CGM's. If anyone has already written such a letter I would appreciate a copy, since it would save me a lot of time.

[Laurie]

Hi Phil - This is from the TX insurance code on diabetes:

§ 1358.056. COVERAGE FOR NEW OR IMPROVED EQUIPMENT AND
SUPPLIES. A health benefit plan must provide coverage for new or
improved diabetes equipment or supplies, including improved
insulin or another prescription drug, approved by the United States
Food and Drug Administration if the equipment or supplies are
determined by a physician or other health care practitioner to be
medically necessary and appropriate.

I'd mention this to the person you contact. Since CGMS meets the definition above, it has forced some insurance to cover CGMS in TX. Not all, but hopefully with continued pressure, it's gonna force more. Hope this helps...
Laurie

[Phil Lerner]

Thanks. I will include this in my letter to the legislator.

[Mary Ann]

I also have BCBS of Illinois and I have the same problem, my A1C is 7.0 and I am in the process of appeals.

[Phil Lerner]

Blue Cross of RI now routinely covers CGMs. I just got mine today. I still can't believe it.

[Jim Devlin]

I live in Michigan and BC/BS has nevered covered CGM for anyone here. All states different. I have heard that same company will begin coverage in Mi. as of Nov. 1.
Has anyone else heard anything about this?