CGM insurance letter/Anthem

[KitKat]

We need to have the doctor write a script of necessity for the CGM. What usually goes into this letter? We have been asked to supply 30 days worth of BG numbers too.

Has anyone had any luck with Anthem? I have a $4000 DME max!! Any info would be great. We are meeting with MM rep at 9am Thursday.

[Mama2H]

I have no info on Anthem but as for the letter of med nec your doctor should know what to write. Try to find out exactly what your insurance would like to see in the letter and let the endo know so they can add that (for example lower A1c or hypo unaware etc...)

I will keep you in my prayers as you persue the cgms, it is worth the work!

[KitKat]

Thank you so much for the response and the good thoughts! I am afraid we are going to need them.

Kathy

[rickst29]

CA is pretty good about it; States with less aggressive "Insurance Regulatory Commissions" and consumer protection laws can be a lot worse. I got coverage with Anthem-NV, in spite of really bad protections here (we're 49th out of 50 in children's health:mad:). But they didn't dare to deny me even once. :D (Nice for them AND nice for me.) BTW, our DME limit for an individual person is only $2000 (family limit $4000), you might want to check that you really will get all $4000 when the claims are all for one individual. (I wouldn't) :(

It's appropriate to wait for a denial before writing a long letter. But I would DEFINITELY NOT use "lower A1C", because: for each study you and your MD can dredge up finding statistically significant improvements, they can find about three which DIDN'T find improvement. Don't even bring up, or let your MD bring up, arguments you're gonna lose!

Instead, focus on dangerous glycemic excursions. Tell them, if he's having numerous Hypos, that A1C is a deceptive test: All the incidents of minor and even extremely dangerous Hypoglycemia make A1C look LOWER and "better". Because of this, the test itself is inadequate and almost irrelevant for assessing IDDM-T1 kids who suffer frequent episodes of both hyperglycemia and hypoglycemia.
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IIRC, the Dexcom prescription form (a 1-page pdf) lists hypo unawareness, nocturnal hypos, extreme excursions, and hospital/ER interventions as relevant criteria. Use those items, and not A1C, as your justification. (The same "complications" apply for MM justification, of course.) These are the things your Endo's letter should list. If it is denied, THEN you can get involved personally and say something like:

"The FDA Approved theses devices to control exactly these problem conditions (MM in 2005, and the similar Dexcom in early 2006), and Hunter needs it to reduce the frequency and severity of their occurrence. Per the treating Endocrinologist's Prescription and Letter of Necessity, it is medically necessary in Hunter's case, and covered by our Contract.

I therefore ask that this denial be overturned, and for a letter confirming permanent approval of this CGMS device and it's supplies. As you know, the CMS-specified billing codes are as follows: A9276 for the sensors, A9277 for the transmitter, and A9278 for the receiver. The billing codes became effective as of January 1, 2008.

If you imagine that this treatment is not MEDICALLY NECESSARY, please provide a reasoned, written response, with full documentation, postmarked within two weeks. If you try to say that “his A1C looks fine, he doesn't need a CGMS”, in direct opposition to AACE treatment guidelines (available at http://www.aace.com/pub/pdf/guidelines/DMGuidelines2007.pdf), you can expect a Court case.

Thanks for your time and efforts to understand Hunter's case. I sincerely hope that this letter has made the issues more clear, and that a Court Case will not be necessary. If you choose to deny, please provide the medical license numbers of the decision maker(s), and an appropriate legal contact's address. Although these persons might be competent and capable of making sensible decisions regarding treatment of Type-2 Diabetes, The Medical Board(s) in his/her/their State(s) might find that Remedial training in Pediatric IDDM-T1 is needed."

So: Expect denial, then send that (First Class Mail or fax, DON'T JUST SAY IT ON THE PHONE!) If Hunter meets more than one of those criteria,they'll probably cave instantly-- they'll SEE that they're gonna lose anyway, and also get hurt really badly in the process. Feel free to use preceding text as your own (that goes for EVERYBODY, I hereby give it away with no conditions :D ). Just make absolutely sure to use only portions relevant to YOUR child's case.

[KitKat]

You are my hero!!! THANK YOU!!!!:D

[Mama2H]

Wow rick, how on earth do you write this stuff? It would take me 2 years to spit out that one paragraph!

[Danda]

The Medical Policy (http://www.anthem.com/medicalpolicies/policies/mp_pw_a049550.htm) for Anthem say CGMS is "medically necessary".

I hope this will help you.

[rickst29]

The Medical Policy (http://www.anthem.com/medicalpolicies/policies/mp_pw_a049550.htm) for Anthem say CGMS is "medically necessary".

The policy is completely incompetent, and my own Anthem Insurance coverage contradicts it. Any Anthem unit which tries to use this "policy" is in for a World of Hurt, and I'd like to help anyone who is rejected on the basis of this "policy".... which is OK regarding the CGMS Gold, but utterly nonsensical in trying to put Dexcom and Guardian-R/T under the same usage guidelines. :mad:

I'm putting in my Boxing Mouth Guard, and hoping for a chance to PUMMEL this! (10 oz gloves to do some real damage, not 12 oz.) :cool: If you've had a CGMS rejection which refers to this policy, or appears to quote it, please PM or Email me.

[KitKat]

I am waiting to hear from Anthem....and when I do....I will let you know...promise.

What do you mean by nonsensical in trying to put Dexcom and Guardian-R/T under the same usage guidelines. Sorry, I don't get it.

I am sure I will be denied. Am waiting to hear "officially".

Kathy

[rickst29]

What do you mean by nonsensical in trying to put Dexcom and Guardian-R/T under the same usage guidelines.

LOOK Carefully:

Under their attempts to restate "Medically Necessity" in terms which save them $$$, they state:

4. Monitoring and interpretation under the supervision of a physician; and
5. For the invasive subcutaneous continuous interstitial glucose monitoring devices only, is used for seventy-two (72) consecutive hours on an appropriate, periodic basis.


These are the usage criteria of the old CGMS "Gold". (Which, BTW, I think that Minimed has just upgraded to use the Guardian-R/T Sensors, which are more accurate than the 2003-vintage technology which has been used until now. FDA Approval just a couple of days ago, IIRC, but OT for the device which was prescribed for your use.)

These are NOT the FDA-approved and labeled usage guidelines of the Dexcom or Guardian-R/T CGMS systems!!! They are to be utilized on a continuous basis, when necessary, and the pt. is encouraged to respond to the readout (and take action after verifying with a traditional bG monitor) themselves. Saying that its only for "periodic use", and that it's results must be monitored and interpreted by a Physician, is a bald-faced lie.

And if BCBS has people who are claiming to have the medical expertise to override your physician's statement of medical necessity, with such nonsense, they can be hurt-- very badly. (All the way up to license suspension, for licensed practitioners. And if they're "practicing" medicine without a license, they're in even BIGGER trouble.) After you get your denial, we need to see if it refers to THIS policy. If it does, we go after them.

If it doesn't, then we look at the reasons YOUR Company used to deny Hunter-- and go after THOSE decision makers instead.

[KitKat]

Thank you so much for all your help. I feel so overwhelmed by it all. I still have not had a response. I wonder how long it will take? I will let you know as soon as I know.

It is so nice to have such a knowledgeable person on our side.

[tjirvin314]

1st--how exactly did you go about starting to see if your ins will cover cgms, do you call the cgms company the doc, the ins???
Who is first??

My daughter is 3 and I would love to have this to help me know how and when to change basal rates etc, she is rarely consistent with glucoses and its so hard to know wether or not to make a change. If I could see a consistant pattern with cgm I think it would help tremendously.

2nd-The big problem I see is her age, 3
We havent had too many ER visits, maybe 2 in 18 months since dx.
We have never had to hospitalize her other than at dx, and she was not dka.
she does spill ketones when she is sick, and they do rise very fast because of her size, but we have always been able to "deal" with it at home, thankfully!!
Do you think we might still have a case to get a cgms?

Any help would be great!
Thanks,
trish

Oh yeah I forgot to mention we too have Anthem (Missouri)
Which is why I was interested in your postings

[rickst29]

When a get around to making a list of 'insurance' Threads for Jeff, you'll find this one moved to the new "insurance" area. (Where PD just posted that the letter we wrote together has just won coverage from BCBS of Kansas City, after several denials :D:D).

KitKat, your case is probably just as easy as his was. (Coverage won on the first try.) And, if they've been sitting on it with no reply for more than a couple weeks, ping them on the phone first, and ask for their mailing address (for certified mail). TELL them that you expect their reply to be postmarked within 10 business days, or at least a letter explaining EXACTLY why they need more time. (Also to be postmarked within 10 business days.) Follow up with a letter which says this, send one copy to them (certified) and another copy to yourself, don't open it when it arrives. (Keep it unopened with the postmarked date.)

That talk about "nonsense" was how I'll describe their attempt to sneak the Guardian, Dexcom, and R/T CGMS devices under the CPT 99250 code as a medical procedure, and not as permanent end-user bG management devices. (That's what they are, and that's the labeling which the FDA approved. End of Story, unless they'd LIKE to be served up with Punitive Damages, too.)

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tjirvin314, your situation is very hard. The FDA approval is only for ages 7 and above, you would be using "off-label". A lot of the Anthem units are getting to be horrid about off-label indications, even when the need is manifestly obvious.

[bhalper]

There is an updated document (July 2008) on the Anthem web site that lays out when a continuous glucose monitor will be treated as Medically Necessary and subject to reimbursement. It can be found here (http://www.anthem.com/medicalpolicies/policies/mp_pw_a049550.htm). The criteria for long-term usage is found a couple of paragraphs into the second section; above it is the short-term criteria that Rick had previously mentioned.

All-in-all, it looks pretty reasonable and rational. If you've been previously turned down for reimbursement, I suggest that you resubmit your claim and/or appeal your declination.