CFMS Journey - Chapter 3 - DENIAL Letter

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Comment by MichelleStu on July 11, 2009 at 7:59pm

I included hypoglycemic unawareness in my initial request, but they didn't go for it. I have sent in the second letter and we'll just have to see what happens next. Thanks all for all your great advice. I really appreciate every ones ideas and energy, I feel very blessed by your words of advice and encouragement.

Comment by Anna Kiff (FatCatAnna) on July 11, 2009 at 12:32pm

Yeah Melissa - that's a good tip. I'd say even if you "weren't" hypo unaware - if it helps you in obtaining your CGMS - use that in your next application letter. Luckily, my insurance never refused me when I applied for the CGMS.

Comment by Melissa Warren on July 10, 2009 at 10:52am

Another thing that was important for our approval of the CGMS was hypoglycemic unawareness, which my husband definitely experiences. Make sure you mention that if it applies to you.

Comment by MichelleStu on July 9, 2009 at 4:16pm

Thanks Michael I understood just fine. I actually worked with my doc on the letter. I wrote it and he signed it. I am receiving great support from my endocrinologist and Diabetes Education Director.

I work for a fairly small company and they don't offer another insurance company and are extremely loyal to our current provider because we are a vendor of the company as well. Many insurance companies are starting to include CGMS in their list of benefits, and that's good enough for me to pursue. I am doing my part to "get it there eventually" :)

Comment by Michael Wiggins on July 6, 2009 at 9:03pm

Okay Darling let's try this again - you want your Dr. to write the insurance company why you need CGMS. He practices medicine and it is harder for an insurance to refute his request because they don't practice medicine either and it creates a legal liability to thyem if they go against his wishes.

If none of this works see if your company offeres another insurance company so you can change at next open enrollement. Also the company HR department or your company's Insurance Broker may have more pull with the carrier than you do. By the way there is a fair amount of literature that a insurance ompany can point to on the accuracy or inaccuracy of CGMS. It has not yet been accepted by the medical community as the best course of treatment for long term diabetis. Sorry I wish it were so. It will probably get there eventually.

Comment by MichelleStu on July 6, 2009 at 6:14pm

Thanks for all the great insight. I called my insurance co. first thing this morning and asked for the requirements to process an appeal, the customer service lady put me on hold for a bit and then came back and said just write your appeal on the back of the denial letter and send it back it... I said "what! no form that needs to be completed", she said nope. I thought that completely odd and decided to write a more formal letter and faxed the letter and a copy of their denial letter.

I stated that the pump should be approved for upgrade because it will not work with a CGMS and that I should be approved for the CGMS because the CGMS is FDA approved medical devise that is widely accepted in the United States and internationally and the pump and CGMS is considered appropriate care with long term health benefits for Type 1 diabetics.

I'm sure I'll get another denial letter and I'll just keep sending them response back. They are going to get so sick of me LOL!

Thanks again everyone, all your ideas and experiences are really helpful.

Comment by Matthew Yarbrough on July 5, 2009 at 10:45pm

check you drug coverage. I was able to get a CGM with a simple prescription when I found it on my insurance drug formulary (just like test strips) at a time when the CGM was not covered under regular health or durable medical equipment.

Comment by Michael Wiggins on July 5, 2009 at 2:40pm

Okay guys here's the ususal process and it could back fire - an internal appeal which is call a reconsideration is not really an appeal. You need to get to level 3 which should involve a insurance company physcian "medical director"and your Endo Doc should write a letter to him which which will satisfy the medical necesarry criteria. Now that you documented all this ask and it is again denied ask for a external review or appeal this along with your endo letter should get you where you want to go. The external appeal should be done by an agency outside other than your insurance company. If none of this works and assuming your insurance plan is insured and regulated by your State Insurance Comissioner you file a well documented consumer complaint.

Sorry you have more work ahead. Because of the cost of CGMS you have to make a medical case for the need for CGMS. The ususal ones I have seen would be your enability to feel if you are going low or in the process of trying to get pregnant. If you have documented good A1C's over a long period of time then it will be precieved that CGMS is mere convience for you. My pump is coming throught the VA and my primary insurance carrier is TriCare - no matter how much documentation I do neither covers CGMS - that why I just ordered a a Animas 2020.

Comment by Jim Huck on July 5, 2009 at 1:19pm

Melissa gave good advice....don't give up. That's what they're hoping you'll do. Appeal, appeal, and appeal, and when you run out of appeals, make a stink in other ways. My insurance company paid for my CGMS after about 6 months. I feel pretty strongly that a CGMS is a powerful tool that gives you a whole new way to approach your management. Ultimately, it will save the insurance companies money. They haven't figured that out, yet.

Comment by Melissa Warren on July 5, 2009 at 10:27am

After receiving two denials from the insurance company, my husband called and notified them he would be filing a complaint with the Dept of Managed Care. The insurance company offered to do an internal appeal. He received approval two weeks later. Don't give up!