Replies to This Discussion

Permalink Reply by Gary on September 25, 2008 at 12:13pm

I just got off the phone with my Minimed guy and I'm upgrading my pump and getting the CGM and it's covered with Aetna. He said it's a recent change.

Times are-a-changing!!!!!!!

Permalink Reply by Jennifer on January 13, 2010 at 4:34am

Are you guys covered 100%? I have Aetna too and just got the CGM and an upgrade to my pump but my plan says durable medical equipment s only covered 50/50 once my deductible has been met. So now I'm making mo. pymts to cover these 2 devices PLUS if I want to continue to use the Dex I need to pay $240 for a box of sensors.

Any suggestions?

Permalink Reply by Rickst29 on February 15, 2010 at 11:42pm

Your "Aetna" plan is different from Gary's "Aetna" plan. Some thing happens with most every mega-insurance company, gazillions of different policy plans being offered in one State versus another.

Does your plan have a maximum Out-Of-Pocket per year, providing a higher rate of coverage after you've paid out a pile of cash? In mine, after we've reached $5000 in co-pays, the co-pay requirements go away: everything gets covered at 100%.

If your policy is similar then maybe, after you've bought the pump upgrade and Dexcom kit, you could reach such a limit during the plan year. Check it carefully.

Permalink Reply by fishinglady on March 26, 2010 at 9:54pm

Your sensors are cheaper than mine. I have to pay 275.00 out of pocket every mo. I have to go with Medicare guidelines and my neighbor on Medicaid gets a $6,000.00 pump and supplies for nothing. Makes you want to get rid of all assets, quit work PRN and sit on your butt. What's wrong with our system? I'm getting the DexCom next week as I have lows of 39 and no symptoms and highs of 300+. I like waking up in the morning. I do get my meter and strips covered but my Dr. had to fight to get me and extra 5 boxes of strips every 3 mo. I've tested up to 9X's a day. fishing lady

Permalink Reply by Stefanie on February 12, 2010 at 3:09pm

I have Educators Mutual and they just approved my CGM (minimed). From what the woman from where I get my supplies from said, mine is the first one they have covered that she knows of! I think my PRN wrote a good letter explaining the potential costs if they didn't. WoooHoooo!

Permalink Reply by Rickst29 on February 15, 2010 at 11:48pm

Congrats! and interesting, because that usually doesn't work. The letters which I occasionally ghost-write don't bother to argue about possible future treatment costs in $$$: I've found it quicker and more certain to remind them how denial of "FDA APPROVED AND MEDICALLY NECESSARY" equipment and supplies, being prescribed exactly per Approved FDA labeling, could cost their decision-making M.D. his/her license to practice.

Permanently!

When it's not merely a fight about money, you can get their attention in a hurry ;)

Permalink Reply by fishinglady on March 26, 2010 at 10:08pm

I have Medicare Advantage and Medicare guidelines won't cover any of this. My Dr. tried every way to get me a pump with no luck. My C-Peptide was not low enough. They want you pancreatic dead and on a transplant list before yuou can get a pump but my neighbor on Medicaid can get a $6,000.00 pump and supplies for nothing. Makes you want to get rid of all assets, quit Prn work and sit on your butt. Who did you write your letter to and hoew did you word it? My Dr. finally wrote a medically necessary letter to my insurance for an extra 5 boxes of strips every 3 mo. and finally got it approved. How do you word a letter for a CGM and have it work? fishing lady

Permalink Reply by Rickst29 on April 10, 2010 at 1:15pm

Your case is almost certainly "winnable". I'm sent you a message about it...

Permalink Reply by Rickst29 on April 10, 2010 at 2:35pm

Not a lawyer, and I do not charge anything for this assistance. I just want revenge on the CEO's getting $10M per year for denying medically necessary treatments, and their "let's deny another one!" customer service boiler rooms. (Yes, just like the stock-fraud boiler rooms in the movies-- I have bad dreams of "Service Representatives" jumping up from their chairs to ring the bell whenever they've inflicted another denial on a policy holder, and the whole room cheers. Grrrr.)

They cannot require E.R. visits in this situation. It's ridiculous-- think of a heart pt. with Arrhythmia, with initial diagnosis at a physician's office. After all the tests, done via appointments, suppose that an internal defibrillator, or maybe a pacemaker, is prescribed. Does insurance get to deny the treatment, merely because the pt. wasn't dragged into an E.R. by an ambulance?

NO! Such a "requirement" would be absolutely bogus, and CGMS is the same. You have vast swings in bG levels, extremely high average bG, and this "durable equipment" treatment is medically necessary. What's their next requirement gonna be, that the E.R. visit "had to occur on a Tuesday"?

Permalink Reply by Annie B on April 10, 2010 at 1:08pm

What exactly is "prescribed exactly per Approved FDA labeling,"?? I'm trying to get my insurance company to approve a Dexcom...refused last year stating "not medically necessary". Too tired to appeal: but, this year, ready for a fight!!! We've already submitted the letter of necessity and many other documents..but I'm sure an appeal will be in order...

Permalink Reply by Rickst29 on April 10, 2010 at 1:17pm

WHAT insurance company? make me a friend, and we'll move forwards from there. Have you received their form-letter-styled initial denial yet?

Permalink Reply by Annie B on April 11, 2010 at 2:10pm

PHCS administered by AETNA--it's through the small hospital where I work and as I understand it--the board has a say in what they cover...(?)

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