Insurance Coverage

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Permalink Reply by Mollie on August 14, 2007 at 3:18pm

Aetna HMO has for some.
I just sent mine in with Aetna PPO and got a request for more information...so in the follow up process.

From what I have read, it really depends on the patient and the overall condition...hypo unawareness, nocturnal hypos - hospital intervention, or just general intervention documentation was helpful for many.

Aetna is big on diagnosis codes...i think my dr wrote me up as 250.83 - which is unspecific manifestations (hypo unawareness is what i think the reason is)

I am interested in your research- you may have more luck on the yahoo group - because i dont think there are too many cgm users on tudiabetes.

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Permalink Reply by John Sangdahl on August 15, 2007 at 3:47pm

Medical Mutual denied me but my wife's United Health Care approved me. I love my cgms. Good luck

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Permalink Reply by Maura on September 4, 2007 at 11:19pm

Hi, Ken. I'm submitting my request to Regence Blue Shield Selections right now. They say that it is not a covered benefit but it's not on their list of we-won't-even-talk-about-this items. I know there's an official term that Lindsay from Medtronic-Minimed used, but I can't remember what it was...It seems that the caseworker may have some influence on the situation, so we'll see what happens. I'll try to remember to update you all when I hear something.

Maura

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Permalink Reply by Jan on September 6, 2007 at 10:25am

United covers on a case by case basis. Minimed also told me that United's coverage for New York State employees will cover the Paradigm Real Time System. We have been verbally approved three times but seem to have a problem actually getting Minimed to send out and bill for the Real Time System. Minimed wants a letter to them from the insurance company with very specific wording. Our insurance company then had to start the whole process again to comply with Minimed's paperwork requirements. Still waiting for Minimed to receive the paperwork it thinks it needs and then send us the sensors and transmitter....... Our insurance company said if Minimed would just bill them they will pay, but that is not good enough for Minimed. They will not accept verbal assurance that the sensors and transmitter are covered. We have heard that when Medicaid provides a code for these items next January, it will be a lot easier to receive coverage.

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Permalink Reply by ODESSA BROWN on June 7, 2009 at 5:30pm

06-07-09 jan,do you know if medicaid is covering the transmitter and sensors now?please send me an email @//odesbrwn@aol.com if you would.thank you// i have not heard that medicare or medicaid will cover the sensors or transmitter.

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Permalink Reply by Terry Keelan on October 19, 2007 at 9:35pm

I just got Blue Cross of California to pay 50% of my receiver and 50% for a box of sensors for my upgrade to the Dexcom 7.

After I first submitted, including my doctor's signed 'Statement of Medical Necessity' and an invoice from Dexcom marked "Paid", Blue Cross asked for additional information - information which wasn't asked for on the claim form, by the way. What they wanted was the 'Procedure Code' for the items. Based on advice read at the yahoo group 'diabetescgms' I resubmitted using procedure code E1399 for the receiver and A9900 for the Sensors. (The Diagnostic Code, BTW is 250.01.)

Two weeks later the check arrived.

I'm a happy camper.

Terry

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Permalink Reply by Ken Winters on October 22, 2007 at 6:36pm

That's great. I've been too discouraged to try and push it any more with my insurance. But maybe I should. I'm only using my CGMS less than 1/2 time because I want the sensors to last a while before forking out another $350.

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Permalink Reply by Maura on October 25, 2007 at 10:33pm

Hi, everyone. I'm 9 days into sensor use and still appealing my insurance company. No new updates on that front, but they did share 11 pages of research summaries explaining their position. It focuses on little to no change in A1Cs, etc. demonstrating that the effect is not statistically significant. They did say that a Star 3 study had not yet been published but they were following that in order to evaluate the information. Is anyone familiar with that study?

Maura

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Permalink Reply by Rickst29 on October 28, 2007 at 12:33am

For Maura (Oct 26):

That's an easy one if you're using the CGMS to prevent dangerous hypos: A1c is an indication only of *AVERAGE* bG, and obviously, if you cut out vast amounts of time spent dangerously Hypo then your HbA1c will go *up*.

A1c is TOTALLY incapable of measuring/analyzing the variability problem, and any competent analyst knows this. So that objection is incompetent FUD. If the ball is now in your court, maybe send a short letter which points out this fact, and ask what COMPETENT criteria they're using to say that the CGMS devices *aren't* effective for the specific conditions which the FDA listed and approved them to treat.

In short: The FDA has found them to be effective. What specific persons at, or hired by, the insurance company are more expert than the FDA to label them otherwise-- and exactly what alternative treatment do they propose to protect you from Hypos, JUST AS EFFECTIVE AND WITHOUT SERIOUS SIDE EFFECTS, while you're sleeping?

In your letter, via first class mail, ask that their response be returned by First Class mail in no more than 15 business days. They'll understand the meaning of that request, (it's threatening to use their response as evidence in Court), and might inspire them to stop trying to reject you with irrelevant, unqualified BS about "it didn't lower their A1c's".

IANAAL, this are just my unqualified amateur thoughts. Consult with a lawyer in YOUR State, who knows YOUR relevant laws and can read YOUR insurance documents, to get qualified advice. (I think that this is a Civil Court thing, not a Small Claims thing.)

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Permalink Reply by Rickst29 on October 28, 2007 at 1:24am

The "Star 3 Study" is here:
http://clinicaltrials.gov/ct/show/NCT00417989?order=1

They want to use this study for two reasons: First, it combines pumping versus MDI with CGMS, so the results are a quagmire of two different major therapeutic changes being made at the same time. But second, and even better for them, this study defines "glycemic control" as better/lower HbA1c.

Minimed is happy to do this study because it might get them a new indication: Pumping with R/T "improves control" for nearly anybody now on MDI. Right now, as you know from your prescription forms, you need hypo unawareness and/or extreme, sudden "dangerous" bG changes to qualify. (I remember those two, I don't remember how many other checkboxes there were to "qualify" the pt. as an FDA-approved CGMS candidate.)

So Minimed hopes this study will allow them to sell lots more CGMS, without needing a history of dangerous bG occurences to qualify. They're hearing "Ka-Ching, new indication!" But, for people who are already qualified as appropriate CGMS pts., this study is totally irrelevant. The study explicitly excludes everyone who "Has suffered two or more documented events of severe hypoglycemia without warning of impending low glucose levels, within the previous 12 months". And study participants must be insulin infusion pump naїve.

If your situation already matches FDA-approved indications, "waiting for this study" is just more irrelevant BS. Even worse (for you), this study DEFINES "changes in glycemic control" as HbA1c. They excluded the people with Hypos, so of course they can use lower A1c as an appropriate stand-in for "better control". But if you're using CGMS to avoid frequent dangerous Hypos, the study is fundamentally irrelevant: Wrong inclusion/excusion criteria, Wrong method of measuring "results", wrong everything. Totally inapplicable.

In a "Boston Legal" show last year, Denney Crane was talking with his son-- after winning the case against him, a case which his son SHOULD HAVE won easily. He said, "You lost the case when you let ME define the question."

Same thing here-- if you let them define the question as "lower A1c", then you almost certainly lose. CGMS doesn't lower A1c in people who's big pre-CGMS problem is frequent Hypos! That's why they propose this study as "The Question", and why you must take care to have "The Question" defined very differently.

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Permalink Reply by Maura on October 29, 2007 at 11:33pm

Thanks for the input. I sent my letter already requesting an expedited review. I am following up again tomorrow. In my letter I went point by point and countered their reasoning, including the fact that one tool they list as a potential alternative is no longer available on the market...the watch thing...Thanks for the tips. I'll update everyone when I get more info.

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Permalink Reply by Rickst29 on December 3, 2008 at 9:30pm

NEW REPLY: The recent study, published by a JDRF-supported team in the September New England Journal of Medicine, found *HUGE* improvements in A1c among randomized, well-trained "aggressive" adult T1 participants using CGMS versus a control group with the exact same quality and quantity of professional support and training, but denied use of CGMS as a tool after being assigned to the "control" group. The results were an absolute slam-dunk, nobody can ever again claim "it's not proven to decrease A1c" for competent, knowledgable, and attentive adult T1 pts. (T1 adults in so-called "aggressive" treatment.) Because it DOES. Anyone who even makes such a statement, for patients of this type, demonstrates themselves to be utterly unqualified and incompetent by doing so-- and WE can feel free to threaten such persons with approaching their licensing Medical Boards, asking to assign remedial action for "practicing beyond the scope of his/her competence". You can't be aware of the DCCT and this study and NOT see that the devices created a SIGNIFICANT improvement in the pt's long-term outlook for complications, unless you *ARE* totally unqualified to have an opinion in this area.

End of story. Ref: (Ref. NEJM 2008;359 “Continuous Glucose Monitoring and Intensive Treatment of Type 1 Diabetes.”)

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