The battle begins

[Denise Force]

Hello everyone! I am very excited to be here! This is my first blog ever, although I have lurked in many of the diabetes web sites reading the blogs before finally deciding to start my own. I chose this site to blog on because I am starting the battle to get CGMS coverage. Before I tell my story, let me give a little background info. I am a Type 1 diabetic for the past 25 years, currently in my late 30's. I have two young children and am a registered nurse. I have used a medtronic insulin pump for the past 15 years, and was approved by my insurance company (Horizon BC BS of NJ) for a CGMS in April of 2007 when I was pregnant with my second child. When I first got my CGMS, I HATED it! (Maybe because I was pregnant and cranky!) The main problem I had was not with accuracy, but rather with getting the darn sensor to stay in me! I constantly knocked the sensor out, and as anyone who has worn one knows, it is a loooong process to restart it. So, like any good diabetic would do, I cried over the fact that this sensor did not change my life, as I had anticipated, and threw it into my "diabetic supply cabinet", never to be seen again.
Well, in a strange twist of fate, I decided to become a pump and sensor trainer for Medtronic, and after my baby was born I decided to give the sensor another try since I would be training patients on it and would love to be able to tell them I actually used the thing! Second times the charm...I LOVED it! Something clicked this time, and me and my sensor devolped a wonderful relationship where it actually stayed in! Sometimes for 14 days!! And the accuracy is wonderful! No more going somewhere, getting involved in something, and wondering if my bs was low. If you have been diabetic for any length of time, you have had this happen before, where, for whatever reason, you are not near your bs machine and immediately, no matter how you felt a minute ago, you begin to feel as if your bs is low. Now your body, in its panic that you are low, begins to release adrenalin, and now you actually feel low!!! More panic! So you start searching for something with sugar, ANYTHING, and usually are able to find a nice can of liquid sugar (ie soda) and down 37 gms of carbs (that you probably didn't need!)Then, when you finally get to your bs machine, still convinced you are low, you test and come back with a in the 300s...or 400s....but with a sensor, this is eliminated. You glance dowm at the pump, see a number, maybe 95, and know you are somewhere in that area. Maybe not EXACTLY 95, but close enough not to panic. And, 5 minutes later, you can glance at it again and actually see which direction you are heading. Wonderful! So at this point you are probably wondering why I am writing a blog about getting coverage for this little miracle device. Well, my insurance company decided in April of 2008 that they were going to adopt medicare guidelines and no longer cover the CGMS and sensors, except for people who already had it. Great, I thought, I HAVE it..I will be fine, right? WRONG!! The powers that be at Horizon also decided that, even for people who had prior authorization, they would only cover 6 monitoring periods in a 1 year period (meaning 6 boxes of sensors in a 1 year period), and after that, the device is considered "investigational". Apparently no studies were done for longer than a year to determine whether a CGMS is beneficial long term. Perhaps, in the mind of Horizon, I would have everything "straightened out" in that one year period and no longer need my sensor. Heck, maybe I'd even have become so "compliant" (their word, not mine!), that I would be cured! Ok, ok, perhaps I exaggerate a bit..they know there's no cure, right?
So, once again, the battle begins. I must submit a letter of medical necessity (again), wait for the denial (most likely), and then appeal. I must print out the pages and pages of reports from carelink I have, documenting my bs running in the 40s for several nights (I am a nightime exerciser!) and explain to Horizon why I NEED this sensor. I must call my doctor to get him on board with me, get him my letter to review and sign, and then hope he will be willing to call them after the first denial. I have to pull myself together and stop being upset over the senselessness of this all and remember that Horizon is a business, not my friend. I have to remember that they can change the rules any time, without consulting me, or anyone, for that matter! I have to continue writing about my experience in the hopes that it will make me feel better, give me the strength to keep up the fight and maybe help all of you out there too!
Just an aside..in case you are wondering why, if I teach for Medtronic, I cannot get free sensors from them, here's the deal as I see it..I am considered an "independant contractor". I am hired just to teach for them, and am not considered an employee of medtronic. Even though the reps who work for Medtronic (nondiabetic reps!) can get sensors to give to doctors, try out on themselves etc., I am on the bottom of the todem pole. I, who could be their biggest advocate, am not afforded this luxury. I do not blame Medtronic for this. Actually, I love Medtronic, but boy would it be nice to be able to show patients my sensor when I go tho their houses for training. There is nothing like seeing a person using the sensor to convince someone to get one. I will still continue to profess my love for my Medtronic sensor, however I will no longer be able to demonstrate its amazing abilities live and in person to my patients! So sad. As it stands now, I have two unopened sensors left, plus the one I am wearing. I am hoping to get at least 10 days of wear out of each one, which brings me to mid August. After that, I am on my own...I plan to keep you all updated on my progress and hope that, with enough requests from patients, Horizon will reverse this very unfortunate decision and allow us to get the first new piece of medical equipment that can help us in the never ending struggle to remain healthy.

[BlondeSwtP]

Best of luck & hopefully things are moving forward for you since August. I had BCBS of Illinois and was denied but as of January this year, our insurance changed to BCBS of New Jersey. Now the ironic part is that I live in Minnesota but my husband's employer is huge - hence the insurance company far way. Anyhow - I go back to my docotor tomorrow. Luckily he is on my side so after we go through the process again with Medtronic and BCBS of NJ - the next step will be to appeal. HOWEVER, I am visualizing and staying postivie THAT IT WiLL be APPROVED :) I figure with my hopes high it will keep me in the spirits of fighting IF need be too. I totally hear ya on knowing you are ok with your blood sugar and then suddenly it is out of wack. The CGMS would be awesome. Currently I have the Medtronic 715 so if approved I will upgrade, etc.

[Denise Force]

It's been so long since I signed onto this website, I really should post an update! After Horizon denied my CGM coverage after originally covering it, they modified their policy to say that, under certain criteria they would cover it. I got letter of medical necessity and made sure to include all the criteria I thought they would be looking for. After originally still denying it and going back and forth with me, they finally decided to cover it. I hear from my diabetes educator peers that Horizon is one of the more difficult insurance companies to get coverage through. It is my opinion that most people can ultimately get coverage through most insurance companies, although it is often a long and drawn out battle. If I can help you in any way, please feel free to email me at [e-mail] Maybe I can give you some guidance for a letter of medical necessity or let you know if your particular insurance co. has covered any CGMs. It is my hope that if enough of us want these, we can require insurance co. to cover them.

Take Care!