How are Standards of Care for T1 Diabetes Determined and by Who???
I'm writing my first appeal letter for a CGM that was denied.
This is what the insurance company said:
"The requested monitor is neither:
appropriate to prevent, diagnose, or treat your condition, illness, or injury: nor it it
consistent with standards of good medical practice in the United States.
I plan to counter the section about CGM not included in the standards of car (is that what they are saying?) by citing research articles showing the benefit of a CGM for T1 diabetes and stating that standards of care are developed based on a body of science showing the benefit of each standard. It takes a great deal of time and funds to develop this body of science.
But how and who actually determines the Standards of Care for Type 1 diabetes?
This is what the insurance company said:
"The requested monitor is neither:
appropriate to prevent, diagnose, or treat your condition, illness, or injury: nor it it
consistent with standards of good medical practice in the United States.
I plan to counter the section about CGM not included in the standards of car (is that what they are saying?) by citing research articles showing the benefit of a CGM for T1 diabetes and stating that standards of care are developed based on a body of science showing the benefit of each standard. It takes a great deal of time and funds to develop this body of science.
But how and who actually determines the Standards of Care for Type 1 diabetes?
Replies to This Discussion
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Permalink Reply by Kд§$ị (ИσvΔ) on -
It's sad how much changes over the years. I use pen needles and the fingerprick, and I don't really know much about the CGM, but I have been trying to look into qualifying for an insulin pump. I am a type 1. I went undiagnosed in childhood and became gravely ill with diabetes right out of high school. Since I was 19 when I was diagnosed, I was at an awkward age where my doctors tried to treat me as a type 2 even though I am a type 1 because juvenile diabetes isn't generally found newly diagnosed in adults. Medical histories in later years revealed my years without diagnosis, but I suffered with an improper treatment for years. I digress. I was told at that age that only the elderly and children qualify for an insulin pump. This last year, I met with the Canadian Diabetes Association and was told by their advocates and by a rep from MedTronic that I am a prime candidate for a pump because of the number of diabetes-related fatalities in my age group, moreso than anyone else. Be vigilant. If there is a Diabetes Association office near where you live (there is one where I live), meet with someone who deals with advocacy. Do your research, and write to the manufacturer of the CGM with recommenations from the ADA. Sometimes if insurance companies refuse your coverage, you can appeal to the manufacturer to sponsor you for one, especially if your test results prove you would benefit from it.
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Permalink Reply by Natalie ._c- on -
Canada is, of course, different from the US, and I somehow suspect that Bug is American, LOL!!
I do wish you luck in your quest! :-)
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Permalink Reply by Peetie on -
I too am Canadian. I have a Type 1 friend who suffered well into her 30's. She says she was a "bad diabetic" so she didn't qualify for an insulin pump. An appeal was made to a local community group..."The Lions" I think. They agreed to fund the pump. She says she is so thankful for the new freedom of the last few years.
As a Special Education Teacher, I have seen many good deeds performed by local community groups. They have funded training for Autistic children, assistive technology for the multi-handicapped etc. In addition, I attended a Diabetes Support Group for a few years. They always had additional funds at the end of the year and spent much time looking for a good cause.
Most community members consider the health and long life of the young to be a top priority. So many would be appalled to read the posts of the young diabetics on here. There is money and empathy out there. Please go for it now!
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Permalink Reply by jeremiah_81 on -
and people are soo worried about the big bad goverenment is going to ration out their care, so much sooo they fail to realize it is already happening, but hey at least the money saved goes into someones pocket in that privately owned company.
not saying is the case here; i just wanted to point out to all the people whom scream and shout at me because i just want to have the abilty to purchase me own insurance but can't because granny and crazy conspiracy man are worried the government won't give them their meds....
the OP's post is a direct example of rationing health care and it is going on in a private for profit industry....odd how that seems to fail mention by the groups whom scream death to obamercare
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Permalink Reply by BadMoonT2 on -
Some people seem terrified that a government bureaucrat will be involved in their health care, but I have trouble differentiating between a government bureaucrat, and an insurance company bureaucrat. The result is rationing either way.
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Permalink Reply by Natalie ._c- on
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So if you and I can SO easily see that, why can't the pols? Are we really THAT much brighter and more observant than the average bear?
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Permalink Reply by BadMoonT2 on
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Ideology colors many peoples views of the world. Instead of gathering the facts and deciding what they think about a situation they look to their ideology for the answer. You hear the Ronald Regan line "government is the problem not the solution" all the time. The problem with this is that unless you eliminate government all together it leads to less effective government some one in government with this view has an air tight excuse not to strive for effective government.
I am reminded a few years ago when then nominee for the Federal Mine Safety Commission was before Congress for confirmation. He obviously was of the government is the problem mindset. He stated that his goal was to abolish the commission, stating the usual "the free market will do it better" line. The following day there was a major coal mining disaster with the loss of several lives. Subsequent investigation showed they were cutting corners on safety to save money. This is what the free market compels and so there is a place for government. We as citizens have the right to demand that government is efficient and effective in spending our tax dollars. Although my example was of the right, the left also has the same problem, concerning blind ideology.
Or, perhaps, we really are THAT much brighter and more observant than the average bear:)
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Permalink Reply by Kathyann on -
My doctor quotes standard of care for Diabetics when she suggested a statin for my cholesterol, which total has always been below 200. My response, well pretend I'm not diabetic then.
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Permalink Reply by mistressbinky on -
My nutritionist said that weight watchers is another version of the diet. Actually, if everyone followed it, there'd be less health problems. It shouldn't be called a diet, but a healthy balance way of eating.
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Permalink Reply by Natalie ._c- on
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Which diet? If you're talking about a high-carb, low-fat diet with lots of grains and starchy vegetables, some of us just can't tolerate it, as much as we'd like to. A so-called "healthy, balanced way of eating" is one thing for a person with an unimpaired pancreas, and average-to-high insulin sensitivity, and another thing for a person with a non-functioning pancreas, and more than usual insulin-resistance. Even in the general population without diabetes, nutrition needs VARY -- we don't all have the same genes, nor the same hormonal balances, nor the same calorie needs. Why do they think one size (diet) fits all?
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Permalink Reply by Leo2 on -
The ADA Standards of Care 2011, Section I (as in eye, not one), dealing with Treatment Goals Not Reached, recommends adding a CGM. To that point, one must show that treatment goals have not been able otherwise to be attained and refer to these goals and recommendation.
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Permalink Reply by Natalie ._c- on
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The problem is that Medicare doesn't give a good god-damn about standards of care, but only the rules that they make up. If they decide that CGMs are cautionary and not part of actual treatment, then they won't cover them, regardless of what any old panel of actual experts says.
I actually don't envy the Medicare rule-makers, because they have to think of the financial impacts of their decisions, but I would also dearly love to be treated as the individual I am, instead of a statistic. We zebras just can't help it.
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