Tricare Prime denied CGM because child under 7...

[Kelly Houck]

Hello everyone,

A bit of background: My daughter, Abby was diagnosed at 16 months in August of 06. She started on the Minimed insulin pump, March of 07 and the corresponding cgm June of 07. Tricare Prime (North Region) covered both cgm and insulin pump 100%. Recently (4 months ago) our cgm transmitter died a natural death (we have been using it 23 months, 24/7) and we submitted an insurance claim for a replacement. Surprise, surprise they are now denying us coverage. We are now in our second round of appeals - I was doing research for my second appeals letter when I stumbled on this website and was hoping someone had some advice to pass along. Their main argument for denying us (and I am having trouble coming up with a good rebuttal) is that the cgm is not FDA approved for children under 7, and tricare does not approved anything that is not FDA approved. I am not quite sure what kind of argument I can make against that. According to them we were approved initially, because it was just a mistake that was made - they didn't realize how old my daughter is? She is now 4.

Abby does not have diabetic complications, but she does not feel her lows and she has wide blood sugar swings. Off of the cgm we fingerprick upwards of 8 x's a day, and it is really a safety concern for us. Since she has been off of the transmitter her lows have increased 50% and many could have been diverted by the cgm alarms. I have the cgm case studies, which we included in our original appeals letter but this argument based on the FDA approval - well I just don't know what to put for that.

Thanks so much in advance,

Kelly and Abby