AUG. 08 UPDATE -VICTORY!! Advice on insurance appeal please (teleconferencing in 3 days!)
Hi everyone!
I have been applying for a minimed cgms for many months now. On Jan. 2nd I'll be having a 15 minute teleconferencing session to plead my case with my Regence Blue Cross Blue Shield of Oregon Appeals Panel. The panel is a physician Medical Director, a Registered Nurse and an Administrative Rep.
Regence has denied my request for a pre-authorization on the grounds of it being 'investigational'.
Aside from the usual "here are the top 3" reasons why approach (which in my case are: plans for pregnancy, occasional hypo-unawareness and a constantly changing level of stress and activity which tends to make me be out of control...) what other persuasive methods work with these insurance giants??
SO, what has worked for you? Has anyone gone through this process and succeeded? Any recommendations big or small would be helpful. Please hurry with lots of advice!
Thank you all tremendously.
Cheers,
Davis
I have been applying for a minimed cgms for many months now. On Jan. 2nd I'll be having a 15 minute teleconferencing session to plead my case with my Regence Blue Cross Blue Shield of Oregon Appeals Panel. The panel is a physician Medical Director, a Registered Nurse and an Administrative Rep.
Regence has denied my request for a pre-authorization on the grounds of it being 'investigational'.
Aside from the usual "here are the top 3" reasons why approach (which in my case are: plans for pregnancy, occasional hypo-unawareness and a constantly changing level of stress and activity which tends to make me be out of control...) what other persuasive methods work with these insurance giants??
SO, what has worked for you? Has anyone gone through this process and succeeded? Any recommendations big or small would be helpful. Please hurry with lots of advice!
Thank you all tremendously.
Cheers,
Davis
Replies to This Discussion
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Permalink Reply by J. Davis Harte on -
Excellent idea...I need to think of possible alternatives like this. How much is the dexcom out of pocket? I think the mm is about a grand. I already have the mm paradigm, so that may be awkward to change... 80% coverage of the supplies would be conceivable though.
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Permalink Reply by Toni Crebbin on -
Well the website says $800, but I think when I bought back in Dec., that included the first set of 4 sensors too. I have a medical retirement VEBA fund that I used to reimburse me for the cost of that, so I actually didn't have any out of pocket to start up. Do you have a flex-plan where you work that you could use?
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Permalink Reply by Marcy on -
Hi! I am currently fighting with Aetna PPO (2nd Level Appeal). Rick was supposedly helping me as well, I have not heard from him since March 19th. I really hope that he is OK. But I am finding this fight very difficult on my own. He was my "ace in the hole."
What is the status on your fight now?
BTW--ECE is my passion!
Best luck to you
Marcy
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Permalink Reply by Denise Bevard on -
So, after my 2nd appeal, with the assistance of my HR dept (told them I WOULD start civil legal action), and the assistance of all the help on this board... I just got BCBS to cover (least I have a letter saying they overturned their previous denial), supposed toget it next week-minimed says it is processing. Of course it did not hurt that I filed the appeal the day I came back from a week off from work ordered by the endo so I could get try and get my BG under control.
It really is just a matter of wearing them down so they KNOW you aer NOT going to go away. Idiots.Since the annual cost of the equipment is less than an ER visit in most places, you'd think that it would be a no-brainer for them...but we all already know logic escapes them most of the time.
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Permalink Reply by terryok123 on -
This may help I am working on this now........
From JDRF's website
STEPS FOR OBTAINING CASE BY CASE COVERAGE FOR CONTINUOUS GLUCOSE MONITORS (CGMs)
http://www.jdrf.org/index.cfm?fuseaction=home.viewPage&page_id=...
http://www.jdrf.org/index.cfm?page_id=106687
i hope this helps..
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Permalink Reply by J. Davis Harte on
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In case this 'hear ye, hear ye' wasn't spotted on my blog, I'm pleased to say it again:
BREAKING CGMS NEWS!! Tenacity WINS!! DECISION OVERTURNED!!
My 13 month-long fight with my insurance company has taken a beautiful turn for the better. The third level of my appeal process was sent to an independent review organization (IRO) last month. The list of items sent included 39 documents, ranging from my bg charts, endo's prescription and letter of medical necessity, academic articles and all the previous correspondences I've had with Regence.
I received a letter from the IRO yesterday saying, "It is the recommendation of this reviewer that the denial of coverage issued by Regence BlueCross BlueShield of Oregon for the Glucose Monitoring System is overturned." :D :D :D :D
Here is another quote from the letter that I'd like to share:
"Even though CGMS in general is not considered the standard of care, in evaluating this specific case, CGMS would be considered the standard of care by the medical community. It would not be considered experimental because greater control of her glucose would result in improved health outcomes compared to standard therapy. The greatest potential for the CGMS with this enrollee is to monitor *trend* of variations in glucose rather than simply the highs and lows in blood sugar. CGMS can provide the trend of glucose excursion. This patient is prone to hypoglycemia unawareness. This feature in the Paradigm Real Time system could be valuable for her to identify hypoglycemia trend, thus allowing her to make an adjustment before a hypoglycemia event actually happens. In addition, there is an alert system in the machine that will alert the patient of hypoglycemia. The sensors features on the Paradigm Insulin pump will likely improve her glucose control, HbA1c and safety."
Please feel free to contact me, share this news, reference this blog or whatever you need to help your own fight. May we ALL enjoy what should be the standard of care for our diabetes management, without having to go through the rather grueling process of appeals.
THANK YOU to TuDiabetes members Marci, Karne and Rick for their input, it proved invaluable. Thank you to ALL of the TuDiabetes members who encouraged me to continue this long and weary battle. Thanks to my family, especially my husband Michael who wasn't so sure my tenacity would actually convince the insurance company, but he encouraged me to continue anyway.
Now, I just need to continue my diligence and patience - Regence should be contacting me soon. Maybe I'll just go ahead and call them!! I'm so thrilled to have won!! What a day for a personal victory, the first day of the Olympics!
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Permalink Reply by Toni Crebbin on
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That's awesome! Your persistence has paid off, and your sharing will encourage others to do the same.
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Permalink Reply by Manny Hernandez on -
CONGRATS!!!! This is great news.
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Permalink Reply by Victoria on -
This is great news. I have been following your appeal process. I work for a large hospital in Oregon that self funds our insurance. They use Regence BCBS of Oregon for the plan guidelines. I am preparing my second (I have been told my final) appeal for coverage for CGMS for my husband. I would appreciate any information you can give me for my appeal. It was suggested I find insurance companies that cover CGMS and provide their critera for coverage. I have been waiting for 3 months for them to respond with the documentation for which they based the first denial. We have been paying for the transmitter and sensors ourselves since January. My husband's A1C has dropped 2 full points in 6 months and he no longer has hypoglycemic episodes. What a relief to be alarmed in the night with dropping BS. The CGMS data that he can download has helped him adjust his basal rates and the sensor readings have been accurate within a few points of his fingersticks. He now has so much more control over not only the low BS but high BS that he was not really aware of just using fingersticks. Thank you so much for all your hard work! Victoria
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