Anyone had success with CGM coverage Blue Cross?

[krstn9@yahoo.com]

I know that I have posted this question once before but I saw that some people have been successful with coverage from BC in other states. I am located in Calfornia and am on my 4th appeal for CGM coverage. My 7 year old son is hypoglycemia unaware (doesn't feel his lows) and has already been hospitalized for a nightime seizure. I have provided doctors scrip, research studies, the cost of my son's hospitalization showing how a CGM would be cheaper than another hospitalization for Blue Cross, etc. Does anyone have anything that was helpful in getting their case through? The response I am getting from BC is that it is not a proven method compared to manual testing. I don't even think they are reading my information and this is a "blanket statement" that doesn't even apply to my case. Thanks Kristin

[funnygrl]

I got coverage through Excellus BCBS for a 3 month trial, which ended up being 1 month due to a paper work snafu. They paid for the transmitter kit, just the sensors the "trial" applied to. I had 2 hospitalizations last year. I got pretty lucky.

[rickst29]

and a lot of the administrative processing is shared with CA. They never dared to deny my claim, not even once, because (like you) I had a history of Night-time Hypos which couldn't be managed by "more testing" without causing severe sleep disruption and it's side effects. I don't know why they're trying this game with you, maybe the NUMBER of my events was critical. Probably, the fact that I was already using CGMS and had an official Medical record of the night and day difference CGMS created in my life (8-12 Glucagons per year before, just one in over 18 months after) was the key.

So much for my story. The first thing to note is, you're in a very good State with an aggressive insurance commission office. If they give you cr%p again, call up the State, they might even provide a lawyer for the Court case if BCBS continues to balk. But they probably won't, not when you show a willingness to play hardball. You should have started 'hardball' after the 1st or 2nd appeal, you've kind of established a pattern of being "easy to deny" which you're gonna need to overcome.
- - - - -

Please post the exact contents of your letter. If they are telling you EXACTLY what you said they are, "is not a proven method compared to manual testing", they are slinging irrelevant mud, and here is the response which I would write if I were in your place:

I have read your denial of my claim for coverage of a CGMS device and supplies for my diabetic son, and your "reason" makes no sense. As everyone familiar with the devices knows, A CGMS provides an indicator of trouble, and is never to be used for Treatment without confirmation by fingerstick test. But it provides a test reading every 5 minutes, even when sleeping-- and no traditional finger-stick regimen can do that. (Not even close. Not in frequency of tests, nor in testing while asleep.) It obviously provides a completely different kind of testing. The devices also issue alarms automatically when they detect that bG appears to be reaching a dangerous level, either high or low. When used with a microphone and amplifier, it can even wake THE PARENTS in another room when such an alarm occurs.

The FDA, in determining these devices to be both safe and EFFECTIVE, did not require that they replace "fingerstick" bG testing. It would have been absurd to do so, they fill a significantly different need. In fact, the FDA clearly states that they must be used WITH traditional bG tests. Nonetheless, the FDA has determined that these devices are appropriate and effective in preventing dangerous Glycemic excursions among patients just like my Son. These devices are PROVEN by the FDA's standards and billing codes have already been assigned and implemented. If you have some star-chamber committee which wants to protect your profits by declaring otherwise, I will bring your actions and incredibly absurd "reasoning" to the attention of the California Department of Insurance.

Your "reasoning" is like saying that "bG testing is not proven effective in Diabetes Treatment, because the pt. must still take insulin to actually treat high bG." Presenting this argument is both absurd and personally insulting to me.
- - - - -

Please respond to this letter in writing, within 15 days, as follows:

(1) Stop dishing out this nonsense and approve my claims, now and in the future, for this appropriate and effective technology. Please provide the title and mailing address for a specific contact on my CGMS matters; or

(2) If you will not immediately approve my claims, then please provide the following:

2-A: The complete text and supporting data behind this claim that "it is not a proven method" for helping patients to maintain safe bG levels while sleeping, as well as at other times;

2-B: The names, titles, medical license numbers, and FINANCIAL INTEREST DISCLOSURES of the Authors of these assessments/studies/analysis papers. By declaring that this technology "is not proven" they are claiming to be "more expert" than the FDA committee members who have approved these devices, and who accepting input from ALL interested commentators before doing so. (I will need to know who these people are before proceeding with legal action); and finally

2-C: The name, contact information, and title of your contact person for this impending legal matter.
- - - - -

Please do not call on the phone regarding this matter-- all further discussion and documentation needs to be in signed and dating writing, via 1st Class Mail, Fax, or Courier Delivery.

Thanks for your prompt attention,
krstn9 (whatever)

This is hardball, and you need to start playing. :D:cool:

[Adinsmom]

and a lot of the administrative processing is shared with CA. They never dared to deny my claim, not even once, because (like you) I had a history of Night-time Hypos which couldn't be managed by "more testing" without causing severe sleep disruption and it's side effects. I don't know why they're trying this game with you, maybe the NUMBER of my events was critical. Probably, the fact that I was already using CGMS and had an official Medical record of the night and day difference CGMS created in my life (8-12 Glucagons per year before, just one in over 18 months after) was the key.

So much for my story. The first thing to note is, you're in a very good State with an aggressive insurance commission office. If they give you cr%p again, call up the State, they might even provide a lawyer for the Court case if BCBS continues to balk. But they probably won't, not when you show a willingness to play hardball. You should have started 'hardball' after the 1st or 2nd appeal, you've kind of established a pattern of being "easy to deny" which you're gonna need to overcome.
- - - - -

Please post the exact contents of your letter. If they are telling you EXACTLY what you said they are, "is not a proven method compared to manual testing", they are slinging irrelevant mud, and here is the response which I would write if I were in your place:

I have read your denial of my claim for coverage of a CGMS device and supplies for my diabetic son, and your "reason" makes no sense. As everyone familiar with the devices knows, A CGMS provides an indicator of trouble, and is never to be used for Treatment without confirmation by fingerstick test. But it provides a test reading every 5 minutes, even when sleeping-- and no traditional finger-stick regimen can do that. (Not even close. Not in frequency of tests, nor in testing while asleep.) It obviously provides a completely different kind of testing. The devices also issue alarms automatically when they detect that bG appears to be reaching a dangerous level, either high or low. When used with a microphone and amplifier, it can even wake THE PARENTS in another room when such an alarm occurs.

The FDA, in determining these devices to be both safe and EFFECTIVE, did not require that they replace "fingerstick" bG testing. It would have been absurd to do so, they fill a significantly different need. In fact, the FDA clearly states that they must be used WITH traditional bG tests. Nonetheless, the FDA has determined that these devices are appropriate and effective in preventing dangerous Glycemic excursions among patients just like my Son. These devices are PROVEN by the FDA's standards and billing codes have already been assigned and implemented. If you have some star-chamber committee which wants to protect your profits by declaring otherwise, I will bring your actions and incredibly absurd "reasoning" to the attention of the California Department of Insurance.

Your "reasoning" is like saying that "bG testing is not proven effective in Diabetes Treatment, because the pt. must still take insulin to actually treat high bG." Presenting this argument is both absurd and personally insulting to me.
- - - - -

Please respond to this letter in writing, within 15 days, as follows:

(1) Stop dishing out this nonsense and approve my claims, now and in the future, for this appropriate and effective technology. Please provide the title and mailing address for a specific contact on my CGMS matters; or

(2) If you will not immediately approve my claims, then please provide the following:

2-A: The complete text and supporting data behind this claim that "it is not a proven method" for helping patients to maintain safe bG levels while sleeping, as well as at other times;

2-B: The names, titles, medical license numbers, and FINANCIAL INTEREST DISCLOSURES of the Authors of these assessments/studies/analysis papers. By declaring that this technology "is not proven" they are claiming to be "more expert" than the FDA committee members who have approved these devices, and who accepting input from ALL interested commentators before doing so. (I will need to know who these people are before proceeding with legal action); and finally

2-C: The name, contact information, and title of your contact person for this impending legal matter.
- - - - -

Please do not call on the phone regarding this matter-- all further discussion and documentation needs to be in signed and dating writing, via 1st Class Mail, Fax, or Courier Delivery.

Thanks for your prompt attention,
krstn9 (whatever)

This is hardball, and you need to start playing. :D:cool:

Wow Rick. ;) We are about to request a cgm and I will come to you if their is an appeal on my hands.

[WestinsMom]

Yeah, I was thinking the same thing. I figured I would go back to this post for an example letter. :) By the way, we are approaching bcbs of Michigan.

[krstn9@yahoo.com]

Wow Rick and all the parents, Thank you for the response. I am ready to play "hardball". The unfortunate thing with Blue Cross is that you never get to talk with anyone. There is an Appeals Department that is totally isolated from Blue Cross and you never get an actual conversation. I will be taking your comments Rick and putting together another letter. I will also be contacting the ADA, AMA, State of Calif, etc. Also a side note. Sometimes your medical professionals are on the board of the insurance companies that can also be helpful. Let the games begin!!!!!!!!!! I will keep you all posted in my fight. Kristin

[OSUMom]

We have BCBS of Delaware PPO (local Anthem) and are waiting for the doctor's office to make initial contact then the games will begin.