Why Insurance Companies Deny CGM Devices?

Comment

Comment by Michelle on June 28, 2008 at 7:36am

I'm a Case Manager for a TPA (insurance) and mom of a 4 year old with diabetes. I fight the fight for all of my cases and usually win (fortunately). Maybe its because we have a sensible Medical Director or maybe its because I am able to present the case and supporting research/evidence in a way that makes it make sense to him. In any case, I HIGHLY suggest to each and every one going through this fight to request a RN Case Manager to help. I realize not all companies provide the service, but I think in my cases I have been able to save a lot of headaches on the part of the patient/parents. I hope to continue to be successful.....and hopefully when we make the decision (probably after my daughter's appt in July) my hard work will pay off and we will be able to get approval for my daughter's as well. Sadly, while attending a recent conference I was able to meet some great folks from Dexcom who mentioned that Cigna (our insurance for my daughter, not the company I work for) will likely automatically DENY coverage :( On a brighter note though I was able to gain MUCH more info and research to help support my appeal that I WILL be fighting! (And in the meantime, will likely just go ahead and pay out of pocket for the CGMS).

Comment by MelissaBL on June 27, 2008 at 2:45pm

I'm in the process of trying to get coverage for a CGMS, too. Fighting the good fight. They say on a case by case basis, we each stand a chance. It's sad that, in that sense, we each have to prove we're "more diabetic" or that our health is more important/more precarious/more worth saving than someone else with diabetes. But maybe we can systematically bring them into the 21st century, even if it is kicking and screaming. I haven't gotten my denial yet, but I'm expecting it. Let's keep hoping and appealing, yeah? I remember when I was crossing my fingers that they'd cover a pump!

Comment by Michelle Curtis on June 22, 2008 at 4:35pm

We are like many who are paying out pocket. So the insurnace wins twice as we will continue to pay as we see the benefits and they won't (hopefully) have to pay for the complications down the road. I won't give up my son's cgms. I will continue to pay. Shame on insurance. Some consider cgms "cadillac care"...this is NOT cadillac care! This is simply caring for diabetes with your eyes open instead of shut!

Comment by George Simmons on June 19, 2008 at 8:29am

The song anaolgy is perfect. I have been denied myself and am ready for round two.

Comment by bethdou on June 18, 2008 at 3:47pm

My daughter was only dx'd about 3 years ago, but I would guess that there were people who had to fight in order to get the first generation pumps and meters covered. When she needed them, our insurance company covered them because those fights were already done. I'm glad that there are people who are willing to fight to get this device covered so that when those improved products and cheaper prices (hopefully) show up, we won't all have to do battle. We've chosen to pay out of pocket for a Dexcom Seven rather than fight, because I'm hoping to be able to GET coverage when improved systems come out and not have to wait 4 or 5 years.

Comment by Manny Hernandez on June 18, 2008 at 6:55am

Fair enough.

Comment by Scott Strumello on June 18, 2008 at 6:52am

Fair enough, perhaps "lemon" was not the best term to use, but I think it is fair to say that this is still a first or maybe second-generation product that is likely to be improved significantly in the coming years, and having been down this road already (remember, I saw the first pumps emerge in 1979 or so, and the first meters emerge in the early 1980's), so I will bet that we'll see improved products and cheaper prices in the future, so I'm not sure I'm ready to rush out and fight to get what's there today ....

Comment by Khürt Williams on June 18, 2008 at 5:42am

IMy insurance does cover the cost of a CGMS and supplies so I agree with Scott. The device manufacturers must work toward reducing the cost of these devices. The decision to deny Kerri was a business decision not a medical decision.

Comment by Scott Strumello on June 18, 2008 at 4:55am

Let me add that the only way to really effectively address this is to abandon the for-profit insurance system we now have ... something I'd LOVE to see happen, but I doubt we'll ever see!

Comment by Scott Strumello on June 18, 2008 at 4:52am

I certainly empathize with this situation, and I haven't tried largely because of this is the situation, but let me play devil's advocate for a moment. First, let's look at the situation from a business perspective: the insured patients are, 99% of the time, NOT the insurance company's customer, rather it is the employers who buy the policies. The insurance companies have a fiduciary responsibility to make a profit for their shareholders (which, by the way, are what many of you're 401K's and/or pensions are invested in, incidentally). They view this from a business perspective, and Gina is right to a large extent, they would for the most part, rather us have complications because the odds are in their favor. Chances are that you will not be covered by them when complications actually do strike (in most cases, it will be paid for by Medicare, so our tax dollars pick up the cost).

The bigger question I think is whether we're being sold a lemon here. This technology largely relies upon interstitial fluid for readings rather than plasma blood glucose measures, and they price these things at several thousand dollars each ... plus about $35 per sensor, which need to be changed regularly (they recommend every 3 days, though most people get by fine at once every 5 days) for perpetuity -- that adds up fast. The real crooks here aren't the insurance companies, but the manufacturers of this technology -- no one is denying them the chance to earn a profit, but they don't have to rape, pillage and plunder in the process!

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