I am the Permanent Legal Guardian of a 9 year old type 1. She has had a prescription for a CGM for months now and her insurance, which is a Medicaid based HMO has denied coverage.
We have been through a grievance, first level appeal, second level appeal, an administrative reconsideration of the second level appeal, and are now beginning the State Administrative Fair Hearing process before a hearing officer.
And we are likely to lose. We have done all of the right things, given them all the proper studies and position statements, all of the proper supporting documentation and none of it means anything.
Our hearing will be scheduled in a few days and we will go, present all of the right information and the hearing officer will rule against us because we do not have any medical credentials and the people the insurance HMO will send do. And they will say that because this child has a great A1C (average of 6.0 and never above 6.8) that the CGM is not medically necessary.