Hi everyone. I want to get a CGMS but have had much difficulty getting my insurance to pay for it because I have not had any incidences requiring emergency intervention for low blood sugars or been hospitalized. I do have some hypoglycemia unawareness and am often into the 20's before I realize it. I know it would help me to control sugars but I haven't found the loophole yet that will allow me to get it covered by my insurance. Any tips or advice?
Aimee have you gotten a letter from your Doctor? If you can get something that talks about you having hypoglycemia unawareness from the Doctor. Plus have you decided which CGM you want. Sometimes the company will have someone to help you work with your insurance company as well. Medtronic is usually pretty good about getting stuff past the insurance companies, but you do need to fight a little bit. You also might want to check out a website that Gina started about the denial for the CGM. You can do that here.
It took me 6 months to get mine. I submitted 4 months of logs, Dr's letters of need and finally a written grievance letter. That 3 month process was reviewed by a 3rd party and found as necessary ... ha ha got it in Feb 2009
The Minimed CGMS is small and easy to use. I have found it helpful, but you still have to do at least 2 finger stabs a day -- sometimes I take a vacation from it - it can be annoying to me.
Aimee, sounds like you just have to be persistent and get the right people doing leg work for you, ie the suppliers (Medtronic).
In Australia, the insurance companies are still reluctant to cover the pump and dont even consider the CGM. I am currently speaking with my new endo (as of 2 days ago) about getting the pump and CGM. New medtronic comes out here in Feb 2010. I had two massive arguements with my insurance company and had to speak with the manager and then quote the right legislation before they conceeded to saying that I was covered for the pump. The insurance companies are not helpful at all. Medronic and your edno/educator should help out though and take the pressure off you, you have enough to deal with just being a T1D.
I too want to get the CGM but it cost $1,200 here and $80 per senor, so the cost is a lot to take.
Do people wear the CGM 24/7 all the time or say just one week out of a month?
I checked out the link to Gina's initiative to ge the CGM covered in the US, good work hopefully it flows to Aus, but I am not holding my breath.
Good luck Aimee, let us know how you go.
Be prepared to put up a fight.
I had to work for a year to get CIGNA (my insurance company) to cover my CGMS. My doctors wrote letters, but like you, I have (knock on wood!) never been hospitalized or had any serious complications, so he silly insurance people didn't think I needed it. I got letter after letter (each was very vague, requesting "more info" but never saying exactly what they wanted.)
After about 9 months, I had had enough. The squeaky wheel gets the oil, you know. I called Minimed, CIGNA, and my doctor's office every week until they would agree to cover it. I was nice about it, but direct. I would always ask, "what else do I need to do?" and explain to them that I would continue to work until CIGNA would cover it. Fighting for CGMS coverage could easily be a full time job! The Medtronic reps/phone operators were really nice and helpful. They also worked really hard to make sure I could get covered.
My advice is to find your local rep for whatever CGMS company you are trying to get (mine is Medtronic Minimed to go with my pump). The rep should be willing to work with you to figure out precisely what the rejection letters mean and how to beat the system. The rep should be familiar with your insurance carrier, and will know what it takes to get it covered.
My doctor and nurse practitioner ending up writing 3 or 4 letters for me, and eventually, I think CIGNA just got tired of me calling - so they approved me.
I didn't even have real hypoglycemia unawareness, so you at least look better on paper than I do!
Best of luck getting it - I know you eventually will! You just have to be willing to bug the crap out of your insurance company until they do what you need them to do .:-)
Not sure what everyone thinks of this, but I have a Dexcom 7 I'd be willing to sell. There's nothing wrong with it, I used it infrequently and was able to upgrade to a 7plus (due to reaching my out-of-pocket maximum last year). I believe I got it in 11/08 and used occasionally for 6 months or less. I then stopped using it because I got pregnant and found it uncomfortable. I have the software to go with it, clip case, etc.
If anyone is interested, please let me know! (also, Austen, may have an idea for you to get sensors cheaper?). Thanks, Rachel
The key is a letter from your physician stating that your hypoglycemia unawareness places you at high risk of accidental harm/death. It must implicate that by not having the CGM, you are at great risk for harm. If your physician words it correctly, few companies can deny coverage. Even patients using the VA medical system can get it covered if they get the appropriately worded letter written.
Persistence pays off! I also had to fight my insurance company for months to get a badly needed pump upgrade and CGM system. I spoke with my doctor about it, they passed my information along to a Minimed rep who contacted me. They submitted a claim to my insurance company (Aetna), and they denied it. I got a letter from my doctor (make sure your doctor knows what to say in the letter to make it clear to the insurance company that this is medically necessary! your rep should be able to help you with this.) I also had to submit 1 month worth of blood sugars that showed a pattern of lows. After my Medtronic rep helped me submit all of these things, Aetna approved my claim! I received my stuff, met up with my pump/sensor trainer, and began using it.
I don't use it all of the time for a few different reasons, but when I do, it is a huge help. Do you ever wonder "am I going to get low?" I just look at the screen of my pump, and it can tell me if my blood sugar is currently dropping.
Good luck and be persistent! Seriously, I think they deny everyone at first just to save money on the people who don't want it bad enough to fight them for it! :)