A Patient’s Fight
Below, read about a patient’s experience appealing Medicare’s decision to deny their Continuous Glucose Monitor (CGM) coverage.
The diagnosis of an individual with type 1 diabetes, T1D, brings many issues to the family. One of the biggest external concerns is the impact of insurance plan coverage (IPC). The fights with IPC cannot be underestimated. The simple fact is a Type 1 desires to utilize the best available tools to manage this condition and minimize the long term dangers of diabetes. My perspective crosses forty-nine years as a T1D. It has covered a time as a teen member and young adult member of my immediate family. This was followed with a marriage and a family who also had to deal with my challenges of stable glucose levels on a daily basis.
In December 2012, the decision was made to add a Continuous Glucose Monitor (CGM) for better glucose control. All necessary requirements and approvals were obtained and the implementation of a Dexcom G4 Platinum Continuous Glucose Monitor, CGM began in January 2013. In May of 2014, in compliance with Federal rules and the requirements of my IPC, my coverage was changed to a Medicare Advantage policy (MAP), and a fight began over CGM coverage. That fight is chronicled here.
At the start of coverage under a Medicare Advantage program, it was supplied with all new necessary prescriptions which included the CGM requirements and re-configuration of suppliers of all my necessary diabetic supplies. In August 2014, I received the replacement of a Transmitter for my CGM. Within two weeks, the MAP forwarded a notice to me that the Transmitter was not covered by the MAP. Now, my challenge became the arduous Medicare appeal process.
Listed below are excerpted descriptions of all possible steps to a Medicare Appeal process:
Level 1 is a written appeal to the Medicare Advantage Plan to reverse their original denial.
Level 2 is a written appeal to overturn the Level 1 denial. This is forwarded to an Independent Review Entity.
Level 3 is a written appeal to overturn the Level 2 denial. This is forwarded to a Medicare Administrative Law Judge for a hearing.
Level 4 is a written appeal to overturn the Level 3 denial. This appeal is filed with the Medicare Appeals Council (MAC).
Level 5 is an appeal to overturn the Level 4 decision. This appeal is filed with a Federal Appeals Court for a final decision with no further appeals.
Concerning the issue of Medicare coverage for CGM units has been detailed and was encouraged by the various Diabetic Online Community postings. The need for clarity by defining the desired outcomes by reduced hyperglycemic and minimized hypoglycemic events would be the approach to employ. The MAP and benefits have an additional compliance factor. The MAP plans include the requirements of the Centers of Medicare & Medicaid Services, cms.gov.
The relevant Medicare ruling to reimburse the insurance plan contractors was issued in January 2014. It is Local Coverage Article: Glucose Monitors — Policy Article — January 2014 (A47238). Under this section, Non-Medical Necessary Coverage and Payment Rules, the following line has been added:
“Continuous glucose monitors (A9276-A9278) are considered precautionary and therefore non-covered under the DME benefit”. For clarity A9276-A9278 are the sensors, the transmitter and the receiver. DME is Durable Medical Equipment. Further it is interesting to point out the fact that this Local Coverage Article covers only seven (7) States. The included States are: Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin.
Steps were taken in the order listed above. Level 1 and Level 2 filings resulted in denials. There is now good news to report on my journey through the Medicare appeal process. My appeals reached Level 3. The Medicare Administrative Law Judge found that my CGM is medically reasonable and necessary as part of my diabetic care. Contained within the ruling was preceding information listed below which was a cornerstone determination to my successful appeal at Level 3.
The following are key points. The best source regarding the success of a recent Federal Court Case and additional facts can be found on the DiabetesMine Website. Search Mike Hoskins, Medicare’s Lackluster Diabetes Coverage…., Published March 24, 2014. Listed below is the link to the site.
Go to the end of the article. There are three recent key comments by Dan Kraft. They are informative, complete and outstanding. The first post on July 4, 2015 deals with the specifics of Case No. 13-CV-990.
On May 26, 2015 Federal Court ruled that the Local Coverage Article cannot be used to deny CGM coverage by Medicare. The reference is Case No. 13-CV-990, Whitcomb v. Sylvia Burwell, Secretary of Health & Human Services.
The second comment by Dan Kraft, dated July 12, 2015 has additional cost factors of an inpatient admission for a hypoglycemic visit, the emergency room with emergency room costs and the added cost for EMT treatment and transportation to the hospital.
The third and final piece of information is the fact that on July 27, 2015, Sylvia Burwell, Secretary of Health and Human Services, did not file an Appeal within the statutory deadline with the United States District Court. In the present matter the Federal Court’s ruling recognizes that government’s refusal to cover a Continuous Glucose Monitor for the management of Whitcomb’s diabetes was not supported in law or fact.
Suggestions and Conclusion:
Individuals reaching age 65 have the right, responsibility and the ability to appeal the denial by a health insurance plan for a CGM. Is a CGM important to your standard care? Meaning is a CGM reasonable and necessary for your care. I realize that for those of us who already wear a CGM prior to turning 65 years young, this seems like a no brainer. We must be prepared to prove our case in the best possible manner.
It is important to file all written communication with proof of mailing. Using US Postage Service Priority Mail Service (pink form) with signature required is one of the least expensive ways to do this. Using this method one can confirm the date received and who signed for the letter(s).
The communication and assistance with my Endocrinologist was a great help. A very key member during the Level 3 Administrative Hearing.
Consider the questions that need to be answered by us. As the person filing the appeal, our documentation may be directed to someone with no knowledge of type 1 diabetes and the importance of the equipment which we utilize to manage T1D.
a. The professional opinions of my Endocrinologist regarding the status of my hypoglycemia throughout the entire process proved to be critical during the hearing.
b. How can reports from software for the equipment, blood glucose meter, pump and CGM devices, be used to pictorially represent the status of the management of our diabetes? The complete 24 hour picture per day via Dexcom Studio reports were a great assistance in the assembly of the data to demonstrate the time periods of certain hypoglycemic events.
c. A math point to consider.
There are a total of 1,440 minutes in a 24 hour day.
How do 10 blood glucose readings compare to 288 CGM readings for an entire 24 hour period?
Can we determine the percentage of time spent in a hypoglycemic event? A 2% time spent for a twenty-four hour day in a hypo level (1,440 x 2%) is equal to 28.8 minutes!
Can we demonstrate improvements in lowering the percentage of time in a hypoglycemic and hyperglycemic states?