Replies to This Discussion

Permalink Reply by Mollie on May 7, 2008 at 7:44am

I sent you an email with everyting i sent to Aetna for appeal. Hope it helps.

Permalink Reply by Rick Phillips on May 14, 2008 at 12:29am

I sent a testimonial.

Rick

Permalink Reply by Kay on May 16, 2008 at 1:08pm

I had to fight with my insurance company, Kaiser, to get their approval. Even after two paramedic visits in one month, they still denied coverage and claimed it wasn't approved under their policy.

I was persistent. I sent 3 letters and called. I called the Appeals department enough that they knew who it was before I gave my name!

I even put up a website to share about how Kaiser was treating me. It is at http://www.BadKaiser.com

Permalink Reply by cindy on May 17, 2008 at 6:12am

Hi Kay, Congradulations on winning your fight. and I went to your blog, i wonder if the ins. co. knew that you did that & it helped? I am going before a "panel of experts" in 2 weeks to plead my case. I guess you already bought the CGMS? We didn't buy it yet though I want to. My insurance company, Independance Blue Cross, calls the device "experimental" even thought it was approved by the FDA. How long have you been using the CGM? Have you not gone low since you started using it?
Thanks for writing, cindy

Permalink Reply by Kay on May 17, 2008 at 2:30pm

Hi Cindy,

I did let the insurance company know about my website. I'm not sure how much it helped. I think they realized that I would keep being persistent until I got the result I wanted. I had already bought the CGMS as I knew it would help me to avoid lows and as I knew I would soon be a mom I didn't want to have to worry about a bad low.

I've been using the CGMS for about a year now, off and on. I still have lows, but not as many and I catch them at the start so it is easy to treat them. My doctor is better able to understand how my blood sugar levels are throughout the day which makes it easier for her to make adjustments to my basal rates.

Kay

Permalink Reply by Salty and Sweet on May 28, 2008 at 8:31am

I just fought and won a battle with my insurance company over both an insulin pump and CGMS. Well, they "approved" coverage, but the medical supply company is having a hard time getting the insurance to commit to paying (completely ridiculous game they are playing).

My case is a bit unique since I am a "Type Other" so I am not sure my letter could help you. But what I did when pleading my case was to make it very personal. I did not rely on studies, or other people's opinions/experiences. What I think was MOST effective was pointing out that insurance should allow me every tool possible to help control my diabetes because in the long run it will save the insurance company money (and went into details).

Just remember the insurance company is in the business of money, not health care.

Permalink Reply by cindy on May 28, 2008 at 9:25pm

Thanks for writing, Salty&Sweet. I do think I also am going to make my plea a more personal one. I am going to relate the experiences we are going through together and how the lows are affecting us both. Even with my constant vigilance, my husband can and does go low. Sometimes I get so upset that i am pretty sure that it will be ME dead on the floor from a heart attack while He is slipping into a coma. Ahhhhh, married life!
One of my favorite lines from what I wrote so far when i describe how dedicated he is to his health is that my husband wants to be "the healthies sick person he can be". I go before the "panel" on June 3rd. I'll let you know how it goes!

Permalink Reply by J. Davis Harte on August 22, 2008 at 12:40pm

How goes the battle?? As a fellow cgms warrior, I want to cheer you on. I'm finally wearing my own cgms after more than a year of appealing (and it's well worth the fight!). I used a combination of personal stories, detached academic deluge of studies and tough language. Look to my page to see more of their response, to give you an idea of why they finally approved it for me.

Update us Cindy!

:DH

Permalink Reply by cindy on August 24, 2008 at 12:55am

Hi, well, we went before the panel of a Dr, nurse & a member of the "Board". Wow, was I nervous. I thought it went well. I presented evidence of his lows (bill for 911 calls and ER visits, copies of published materials). I sited articles. They asked questions which I gave clear answers to. We saw them on a Tuesday. Got the response on Saturday. Turned down again. Still saying that the CGMS is not proven effective and/or necessary for home use. My last recourse was to request an "External Grievance". An independent "Entity" called a Utilization Review Entity is assigned by the PA Dept of Health. It evaluates all the materials already presented and any additional info I want to add. I had a month to get stuff together.I never worked so hard, I was on the internet for hours & hours every night. Such research. I printed every single article that mentioned anything about the CGMS. And while there is ALOT written & published about the CGMS, not many are specifically about PATIENT OWNED CGMS. And that was one of their points. They have 60 days to respond and then that is it for us, I think. I don't have the money to sue. If we are turned down again, all my appeals are exhausted. And I am not feeling confident but I know I presented a strong argument.

Permalink Reply by J. Davis Harte on August 24, 2008 at 10:24am

This sounds so similar to my battle... I kept my hope level as low as I could while I was waiting for the Independent Review Organization (your URE?) to decide my fate. They said yes! My husband didn't think they would at all...but their wording was something like this - 'although the CGMS is not standard of care for all patients, in this patient's case (me!) it needs to be considered the standard of care.'

I'm keeping my fingers crossed for you - your husband definitely sounds like he needs it! Although, I really think all people with diabetes who are willing to learn such new technology should be able to take advantage of such advances...

Keep us posted.

:DH

Permalink Reply by cindy on August 24, 2008 at 9:05pm

Wow, thanks so much for the positive thoughts. The fact that you had a similar situation and won, that makes me feel a little better. I'm so glad it worked out for you. I will let you know when I find out. Thanks, Cindy!

Permalink Reply by Bernard on September 8, 2008 at 10:24am

Cindy

There's a new study that shows how CGM improves blood sugar control. Maybe that will help you in your fight with the insurance company.

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