When insurance doesn't cover dexcom

I used to have a dexcom when I was on my moms insurance. At the end of last year, my mom left her job & we had to switch over to my dads insurance. His company is with UMR. They don’t cover dexcom so I had to go back to testing my blood 6x a day. I’ve always been in pretty good control of my bloodsugars & the 13 years of having diabetes I never passed out or had been hospitalized for it. Year 14 comes around (when I no longer have my dexcom) & theres now been 3 instances which my parents have found me passed out. Every time Ive had one of these severe lows that leaves me unconscious its been in the middle of the night when I was asleep. This last time, my alarm was going off for work at 5am & when my parents realized my alarm had been going off for 5 minutes & I hadn’t shut if off, they knew something was wrong. They came in & I was unresponsive leaving them no choice but to use my glucagon. This was the third incident in less than a year that I lost consciousness & It required my parents help.

With all that being said, im trying to get my doctor to over ride the insurance & tell them they have to cover my dexcom due to severe lows in the night. It scares me that one day Im not going to get lucky like I have the last 3 times. If my alarm for work wouldn’t of been going off at 5am that morning, who knows what would’ve happened if my parents wouldn’t of came in to check on me. Ive been diabetic 14 years & this is the first time I’ve actually been really scared to sleep at night because this is the THIRD time in a year something like this has happened.

So, if anyone has had an issue with getting their insurance to cover dexcom & found a way around it, or if anyone has any advice on dealing with this type of issue, please let me know. At this point theres still hope my doctor may be able to get them to cover it, but I keep thinking about the “what if” because I just want to be prepared & have a backup plan if this doesn’t work out.

Thank you!

Keep in mind, @brookel, that one constant of TypeOneDiabetes is CHANGE. For effective diabetes management we must be flexible and be ready to change or modify our regime. During the last seven decades trying live well with diabetes i have seen many devices come and go - and insurance coverage is only one element.

Dexcom is NOT the only supplier of real-time glucose devices. I very strongly suggest that you look into some of the various choices.

I don’t know your insulin regime, but I strongly urge you to investigate and most probably reduce your dosing. The number of severe hypoglycemic events you are experiencing is very concerning and needs attention. More attention than just a CGM which you are using to address a symptom brought on by other factors.

I apologize if this sounds tough, but depending on a particular device to "rescue you " is not a substitute for insulin management.

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I’ve been using a CGM for many years now (always Dexcom). When I started my doctor had to document medical necessity - I was experiencing hypoglycemic unawareness - but to the point of passing out - but that was enough for my insurance to cover it. I’ve found my doctors or persons on their staff are quite adept at navigating insurance requirements even with different plans, and with your history of loss of consciousness I would think it would not be too difficult.
As @Dennis already said, getting your basal insulin set correctly is key to help avoid these episodes, and the CGM should be a tool to help you track where you are so you can take steps to keep the severe lows from from in the first place - although the alerts are a Godsend when they come as well as when they are approaching.

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While I see where you’re coming from, I’ve been working along with my doctor on the issue with the random nighttime lows & we have changed & reduced my basal & I:C ratio many many times. However, It happened twice while I was on my pump & then as of 3 months ago, my insurance told us they will no longer cover my pump supplies, so I was recently put back on shots which has been a whole new nightmare in its self & has changed a lot of things. I went from having great a1c’s for years to now having what will probably be my worst…

I understand Dexcom is not the only supplier of CGMs & have looked at other options such as the libre, but I do not like that it does not alert me, as that’s the whole reason I had dexcom before. Not to mention my insurance doesn’t cover any CGM. Its not like my lows are every single night either, there’s been no trend. My severe lows have all been very random when they happen. So while I respect what you’re saying, I know how much better my control was when I had my dexcom & I had the alerts at night to help prevent any dangerous night time lows. I’m not just going to give into the insurance company & not fight for something that helps me with my management. Even if they won’t cover my dexcom in the end, I want to atleast know I tried & looked at all my options to help prevent this happening again.

Thank you! This gives me some hope. Im totally conscious if im going low during the day but within the last year ive had 3 lows where I was hypo unaware. It was like every 4 months. So it wasn’t like it was constant or happening every night which makes it hard with insulin adjustments when its not a trend. I honestly don’t have many hypos at night, but when I do, sometimes I wake up & drink juice & other times I don’t wake up at all which is what makes it so scary. You can be in great control, but every once in awhile you will probably have a hypo at night that could be caused my many different reasons. I just liked having my dexcom more so as an extra thing to help. My parents used to follow me on the follow app which gave all of us some piece of mind when it came to thinking about “what if I have a low blood sugar tonight?” Ive never fully relied on my dex because like I said, my overall control has always been pretty good. But it definitely does scare me when I think about how theres always the possibilities of a random low during the night.

Hi @brookel. Forgive me for being nosey but why did your insurance suddenly stop your pump supplies? I’m asking because a while back I ordered some CGM supplies from my usual supplier and got a call from them that my coverage was denied! I contacted my insurance and nothing has changed - apparently there was an issue with the way the supplier processed the order (the first and only time ever). My doctor had to jump through some hoops but my coverage was restored.
Also some supplies are now covered under pharmacy benefits rather than durable medical equipment, where they fell before. I hope one of those is the issue as both can be fixed - I think the second example is more likely.

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Not nosey at all! I should’ve explained! So really long story short, I’m in college & on my parents insurance. My mom left her job months ago & so we had to go on my dads insurance for the time being. So his insurance is what won’t cover my pump or dexcom. He’s with UMR which is a United Health Care company. But I recently heard that UHC has made a deal with tandem (which is what pump I have) to cover their pump. So Im actually calling them tomorrow to see what I can do. UHC only covered Medtronic pumps, up until a couple months ago & now they apparently cover tandem. I didn’t want to have to switch to Medtronic just because of insurance only because I really liked my tandem pump & I had the Medtronic one before, but I personally just wasn’t a fan. My mom now has a job that has BCBS insurance, but my dad would have to quit his job in order for us to go back on my moms insurance. So thats kinda the short story of everything thats going on. Once we can go back on my moms insurance all this will be straightened back out. But thats still 3-4 months away until we can do that. So this is the dilemma im in being on my dads insurance, If that makes sense?

I wish you well on your call!
While the pump is your tool of choice many people do well on shots. If it were me and I had to wait 3-4 months for the TSLIM, I would take shots in the meantime rather than getting into a long term relationship with another pump - keep in mind you have to keep it until the warranty ends, typically 4 years.
I don’t know much about UHC - I think I heard they would cover Tandem of the person was already on it, but otherwise Minimed was their sole pump. That was a while ago though and I hope you heard right about them opening up to Tandem.
Let us know how it goes!

Have your dad talk to his HR department as well. They can often help with these types of situations. I remember when UHC made their Medtronic only decision that they would cover supplies for other pumps if you were already on them, at least until your warranty period was over. Now, you may be at that point, or they could have changed their policy. But, my experience as a father of a T1D is that if you are a squeaky enough wheel, they will give in. Never hurts to get your congressman’s office involved either. Frequently a call from a congressman’s office will result in a whole new attitude from a insurer. Good luck, I hope and pray you can get the coverage you need.

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I know depending on how your insurance or wherever you get your supplies can cause your insurance not to cover. I know my insurance doesn’t cover it if it is calssified as medical supplies, but will cover if it is a pharmacy item! I would call Dexcom and ask for help with this issue. That’s what I did and my coat went from 500 to 100 for 3 sensors.

Stay strong! Hope this helps

I recently went through the whole insurance coverage push. UnitedHealth Care was covering all my supplies under durable medical equipment but recently shoved the CGM stuff as a whole over to Express Scripts. Express Scripts wants me to use dexcom cgm but it doesn’t work with the auto mode on the 670g medtronic pump which UHC forced me to choose because of their exclusive deal. I luckily am only a couple of months from a new pump and UHC told me the TSlim x2 is covered under my plan now. Life changes do make it harder on us sometimes but unless you are independently wealthy you have to roll with the punches. The statement of medical necessity will get around some insurance issues, i hope that it does work for you. I have been a pumper for 20 years, i can’t imagine switching back to shots, but I would if no other option was available.

Hi Brooke,
Sorry to hear your insurance stopped covering your dexcom. I had to jump thru a few hoops with my insurance> I had to get it covered under durable equipment at one point then under a medical specialties under my main insurance so you may have to dig deep into the plan

Good Luck,
Glenn

i have had just the same as what dat wabbit said, “I ordered some CGM supplies from my usual supplier and got a call from them that my coverage was denied! I contacted my insurance and nothing has changed - apparently there was an issue with the way the supplier processed the order…” occasional CGM & (rarely) pump reorders. Hate to say it all kinds of insurance-involved stuff happens. and not just diabetes related. So no choice but be overly persistent & fingers crossed with EACH subsequent call.

Persistence pays when insurance is supposed to(:wink:).

I’ve had similar problems with OptumRX covering and then not covering various CGMs & insulins. However pretty much every insurer/pharmacy benefits manager (pbm) will cover a CGM for a Type 1 diabetic, and if you haven’t already called the PBM (# should be on your insurance ID card) do that. They may have you incorrectly listed as a Type 2, or they may cover a different CGM such as Freestyle Libre. The new Freestyle Libre 2 (just approved by the FDA) has alarms. Don’t give up, and push your endo to fight for you with the PBM/insurer.