Why Insurance Companies Deny CGM Devices?
When we learned about the news that another person with diabetes had been turned down in her request to her insurance company to cover her CGM (Continuous Glucose Monitoring) system, we had to raise our voice. This time it was Kerri Morrone, but there are just TOO MANY people with diabetes that are having to go through this, and it's completely wrong!
Replies to This Discussion
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Permalink Reply by Melissa Warren on -
We were denied the CGM by Cigna. They are considering it to be experimental. We are trying to appeal this. My husband has had diabetes for over 25 years. He has hypoglycemic unawareness. How can it be experimental to give him a tool to help him monitor his highs and lows and make an informed decision?
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Permalink Reply by Chadd on -
I have called my insurance company every month, well like three times a month. The first, the fiftteenth and the last day of month. I always get the same response that is concidered experimental and not a neccessary medical device. I'm told to call next month to see if they have accepted it or not. I just get the same response everytime.
We pay enough for insurance the way it is, so why do we have to put up with these issues all the time?
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Permalink Reply by Steve on -
Melissa,
I too was just turned down for a CGM by Cigna for the exact same reason. This device has FDA approval, so how can they deny it?
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Permalink Reply by Bob @ joy of diabetes on -
I have been type 1 for 44 years and am hypo-unaware at least half or 3/4 of the time. I supplied Blue Cross Blue Shield of Florida with a letter of medical necessity from my endocrinologist. After sending it twice to Dexcom and following up, BCBS called it experimental......hmmmm, Ive been on it for well over 1.5 years and close to 2. What that means is that I get to keep paying cash every month for the sensors.
I think the true sin here is that the U.S. government does not allow your medical expenses to be tax deductible until it is 11% of your gross income. Taxing my medical supplies that I am forced to pay cash for is even more sinister in my opinion. Since I am self employed, I am at an incredibly high tax rate as all business income/profit is seen as personal income(let me assure you, it isn't).
It equates to me paying 35%-40% more than the listed price of the sensor(income tax they cahrge me)....the true cost of the sensor is $84 dollars, not $60....I believe that is immoral.
With 5 children(that I don't get to deduct), a home morgage (that I don't get to deduct)High medical costs(that I don't get to deduct)....I am tired of carrying the load and then getting slapped for my medical costs as taxable. Wanna lower the cost of your medical care dramatically...it should be non taxable and totally off limits........
Keep Going...........................Peace, Bob
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Permalink Reply by Scott Strumello on -
I certainly empathize with this situation, and I haven't tried largely because of this is the situation, but I responded to Manny's post on this topic already. Let me play devil's advocate for a moment. First, let's look at the situation from a business perspective: the insured patients are, 99% of the time, NOT the insurance company's customer, rather it is the employers who buy the policies, and they are under pressure to keep costs under control or they risk losing customers. Its no secret that the insurance companies have a fiduciary responsibility to make a profit for their shareholders (which, by the way, are what many of you're 401K's and/or pensions are invested in, incidentally), and frankly, they make money, but not on a ROI basis at a comparable level to the drug and medical device companies. The insurance companies are forced to view this from a business perspective, and Gina is right to a large extent, they would for the most part, rather us have complications. Insurance is all about managing odds, and the simple fact is that by denying this coverage, the odds are in their favor, because chances are extremely high that you will not even be covered by them when complications actually do strike. First, many people are likely to have several insurance carriers over the years due to job changes, or simply because employers negotiate deals with new companies (see my post here for more on that. The simple fact is that in most cases, those costs will be soaked up and paid for by Medicare, so our tax dollars pick up the cost, but few if any insurance companies will be saving much of anything by paying the cost of this costly technology, rather, they have everything to lose by paying it and stand to gain little if anything by covering it.
No one seems to question whether we're being sold an overpriced lemon here? This technology largely relies upon interstitial fluid for readings rather than plasma blood glucose measures, and they price these things at several thousand dollars each ... plus, the bigger expense is the roughly $35 per sensor (when chances are, they actually make them in China for pennies on the dollar), which need to be changed regularly (they recommend every 3 days, though most people get by fine at once every 5 days) for perpetuity -- that adds up quite fast.
In my opinion, the real crooks here aren't the insurance companies, but the manufacturers of this costly technology -- no one is denying them the chance to earn a profit, but they don't have to rape, pillage and plunder us and our healthcare providers in the process?! Let me add that the only way to really effectively address this is to abandon the for-profit insurance system we now have ... something I'd LOVE to see happen, but I doubt we'll ever see it! The odds are that we still won't have universal coverage by the end of 2009, regardless of who wins the White House, because we're now so far into debt for the Iraq war that whoever is in the White House or in Congress will really have their hands tied as to what they can realistically hope to accomplish. Who should we be thanking for that?
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Permalink Reply by Manny Hernandez on -
From a strict business point of view you are right, Scott.
The reason insurance companies deny people CGMS today and used to deny pumps before is because they can, so I do agree that the way to get out of this situation is for our health to be treated as an item that has a dollar tag on it.
One thing that I am not sure I completely agree with is that the product is a lemon. Overpriced, it could be, but having a device that helps you follow trends helps big time with better control.
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Permalink Reply by forcequit on -
Digg this page for more exposure.
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Permalink Reply by Gina Capone on -
I have aetna, i heard that United Health care is approving.
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Permalink Reply by Mollie on -
Aetna paid for my Receiver and 4 boxes of sensors....(one box with my receiver/transmitter claim) and then 3 boxes on an additional claim.
Now they deny everything. Saying long term use is not covered. This is the exact except from their policy---they pay for 2 sessions a year---not sure if the hassle is worth it. My endo is set up for a peer to peer discussion about my case specifically----she will talk to the dr at aetna.
Continuous Glucose Monitoring Devices:
Aetna considers continuous glucose monitoring devices (e.g., MiniMed Continuous Glucose Monitoring System, Guardian Real-Time Continuous Glucose Monitoring System, and the DexCom STS), which are used to continuously monitor diabetic persons' blood glucose levels over a three-day (72-hour) period, medically necessary for persons with type 1 diabetes who have either of the following problems in controlling blood glucose level, unresponsive to conventional insulin dose adjustment:
repeated hypo- and hyperglycemia at the same time each day; or
hypoglycemia unawareness.
No more than two CGMS monitoring periods are considered medically necessary within a 12-month period. Aetna considers the long-term use of continuous glucose monitoring devices for home self-monitoring of blood glucose experimental and investigational.
this was last reviewed 6/10/2008 and will not be review again until 1/22/2009
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Permalink Reply by Chadd on
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This article was in our news papers two days ago. Thought it was interesting, due to they had raised our rates last year and now again they want to push for a larger percentage increase..... I thought that it would go in this part with Insurance Companies, if not, I appolize, in advance.
Blue Cross Blue Shield of North Dakota is asking for a 14.8 percent increase in premiums for a group that provides health insurance for individuals, including those who are self-insured.
The request, if approved, would take effect Aug. 1 and would apply to the so-called “bank depositor’s group,” which includes approximately 40,000, Mike Unhjem, the insurer’s chief executive officer, said Friday.
The North Dakota Insurance Department is still reviewing the request, which Unhjem said was submitted six or seven weeks ago.
North Dakota Insurance Commissioner Adam Hamm said he expects to make a decision on the premium rate increase in the next two weeks.
“My office is still in the process of analyzing the request,” he said. A few days ago, his staff requested more information from the company.
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He could grant the increase, reject it, or modify it, usually in the form of an increase below the level requested.
Last year, Blue Cross Blue Shield was granted a 9.3 percent increase for the bank depositor’s group, which provides individual coverage. But the Blues sought a 17.3 percent increase for employer groups, and received a 9.9 percent increase.
Blue Cross Blue Shield will submit premium requests for employer groups later this summer, Unhjem said.
“It’s too early to speculate on any range” of proposed increases, he said.
Unhjem said the lower premium increase granted last year for employer groups, as well as higher-than-projected medical inflation, now running at 11 percent, combined to produce a possible $22 million shortfall confronting Blue Cross Blue Shield.
The Blues put medical providers on notice that they might have to withhold up to 2.5 percent of payments, starting Aug. 1, in the event that it is required to deal with the shortfall. The company is trimming about $4 million in administrative expenses, which would bring the operating loss in line with a projected $15 million deficit.
Fargo lawyer and state representative Jasper Schneider, a Democratic candidate challenging Republican Hamm in the November election, said he would not rely on Blue Cross Blue Shield numbers alone in reviewing the request.
“I would rely on my own actuaries,” Schneider said, a step Hamm said he is taking. Schneider also would invite public comment on any proposed rate increases.
“I would solicit public feedback,” Schneider said. “It gives you a unique insight on how the insurer is operating.”
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Permalink Reply by Bob @ joy of diabetes on
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Let's say that instead of losing money, they are really making 10-15%. That is still within or well below what the government is charging us....10-40% on top of the cost of the medical supplies. Medical should not be taxed espescially as the cost of health care is climbing dramatically.
I want Blue Cross and Dexcom to make a profit as they are providing a product that I want to be able to buy next year too.(No profits--no sustainable company).
It's the added cost of 10%-40% that the government takes......a much greater profit margin than most companies ever see.......
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Permalink Reply by Diana on -
I was recently approved by Tricare for a CGM. If anyone has Tricare look into it. Tricare is approving the CGM on a case by case base. Like everybody says, if you have hypoglycemic unawareness or you titer tarter all day it should help with your approval. It took a month to get approved and my endo wrote a letter to Tricare to express the necessity of this device. My endo also pointed out that my husband and I are planning on having a baby in the near future.
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