I had finally made the decision a few weeks ago to go ahead and order my own Dexcom system. I had a couple lows in the 30's and 40's before I could really feel myself getting low and that scared me. I wanted to have a heads up. After 13 years of this, I felt I might finally have unawareness of lows.
Well, Dex had to get a third-party approval to make sure my insurance would deem it medically necessary and they denied me. The explanation doesn't even make sense (misspellings and grammatical errors are theirs):
"A lifetime continuous glucose monitoring devise is not considered medically necessary based on the enclosed records and standards of medical care. There is a glycemic log over 1 month, but short-term CGMS has not been used in the patient to improve her control. Hypoglycemic episodes are uncommon, and there is not documentation of frequent episodes of hypoglycemia requiring acute hospital management. There is no established evidence of nocturnal hypoglycemia or hypoglycemia unawareness. She mainly exhibits hyperglycemia and further improvement could be achieved in adjusting the diet and insulin regimen. There is not documentation of type 1 diabetes. She does not have recurrent episodes of ketoacidosis, hospitalizations for uncontrolled glucose levels, and frequent nocturnal hypoglycemia."
Is it just me or is this completely baloney??
1. "but short-term CGMS has not been used in the patient to improve her control." Yeah, duh, I'm trying to GET a CGM so that I CAN improve my control. Hello, is there anything in that cranium?
2. I'm still adjusting to life on a pump, so my basel rates do need to be adjusted and that is why I've been running in the 200's--no, I don't have a lot of hypoglycemic episodes now...I'm trying to PREVENT them!
3. "there is not documentation of frequent episodes of hypoglycemia requiring acute hospital management." You want me to be sick enough to require hospitalization before you will approve me for a small machine that will help prevent hypoglycemia that requires hospitalization??
4. "further improvement could be achieved in adjusting the diet and insulin regimen." I have been working my TAIL off to improve my diet. It's better than most people's, I can tell you that!
5. I could go on, but I'll make this the last point since it makes me incredibly angry: "There is not documentation of type 1 diabetes." Where did this idiot go to medical school??? They need to revoke his/her license immediately! What have I been suffering through for the last 13 years?? I'm on insulin...that's approved by insurance. They pay for it. I just had to prove my type 1 diabetes to get approved for my Omnipod. But there's no proof of type 1 diabetes now? Really.
I'm definitely going to appeal this decision. I'm just waiting to hear back from my Dex rep and see if he can provide any advice or help. Has anyone else been here? Did you get this same stupid reasoning that I did?
I guess I've been fairly lucky so far with not running into too many idiots like this when dealing with insurance. My luck seems to be changing now....
To update this:
I did a one week trial of a Dex sensor and loved it. I really missed it when I had to hand it back to my CDE. My doc and the CDE have turned in all the requested paperwork for an appeal and I'm in touch with a rep from Dexcom every couple of weeks to see how things are progressing.
So far, nothing. It's been over a month and I'm worried they're just going to deny me again. I really wanted to get it this year since my deductible is already paid. Here's hoping....