Aetna Denial of CGM as experimental - Help with Final Appeal

[Sherri A]

I am in the final appeal process with Aetna for my daughter's CGMS. Aetna is denying it based on it being experimental…." There is insufficient evidence to support the prolonged use of continuous glucose monitoring devices as an adjunct to home blood glucose monitoring. The potential advantages of adjunctive use of CGM devices in managing persons with poorly controlled diabetes are theoretical. There are no adequate prospective clinical studies in the peer-reviewed published medical literature demonstrating that the use of continuous glucose monitoring devices results in durable improvement in outcomes of individuals with diabetes." The letter goes onto state "Those for or in connection with services or supplies that are, as determined by the Claims Administrator, to be investigational and experimental, because they do not meet generally accepted standards of medical practice in the US."

I have previously submitted letter of medical necessity, FDA approval letter, multiple studies as referenced by MiniMed and JDRF (although I would like to provide more current ones if available). I have handling insurance by the protocol laid out by MiniMed and JDRF. I have one more chance and appreciate any help I can get!

Has anyone been successful in Aetna covering the CGM and supplies? If so, how were you able to get past their clinical policy bulletin denying coverage (other than just twice a year).

[Stacey Nagel]

check out and join this group:

diabetescgms@yahoogroups.com (diabetescgms@yahoogroups.com)

they have tons of files on appeals etc...
and its a great source of cgms info
__________________

[momtojess]

I am in the final appeal process with Aetna for my daughter's CGMS. Aetna is denying it based on it being experimental…." There is insufficient evidence to support the prolonged use of continuous glucose monitoring devices as an adjunct to home blood glucose monitoring. The potential advantages of adjunctive use of CGM devices in managing persons with poorly controlled diabetes are theoretical. There are no adequate prospective clinical studies in the peer-reviewed published medical literature demonstrating that the use of continuous glucose monitoring devices results in durable improvement in outcomes of individuals with diabetes." The letter goes onto state "Those for or in connection with services or supplies that are, as determined by the Claims Administrator, to be investigational and experimental, because they do not meet generally accepted standards of medical practice in the US."

I have previously submitted letter of medical necessity, FDA approval letter, multiple studies as referenced by MiniMed and JDRF (although I would like to provide more current ones if available). I have handling insurance by the protocol laid out by MiniMed and JDRF. I have one more chance and appreciate any help I can get!

Has anyone been successful in Aetna covering the CGM and supplies? If so, how were you able to get past their clinical policy bulletin denying coverage (other than just twice a year).

How old is your child? We were denied experimental because our dd is only 6.

[SaltyAndSweet]

I don't have much advice as I am fighting GreatWest Healthcare for a CGMS right now too. I received the same excuse from GW. It sounds like you have done everything I have tried. I have one final appeal left and we are currently collecting all the ammo we can get.

Has your doctor been able to do a peer-to-peer with whom ever is making the decisions at Aetna? If your doc can talk to the person over the phone, it may help your case. Maybe you will be "allowed" this during your final appeal.

Stacy, the link goes to an email message, do you have a link to the group? Thanks a bunch! :D

[Stacey Nagel]

http://health.groups.yahoo.com/group/diabetescgms/

ok, i hope this one works....

[Mrs_Woody6]

I'm on the second appeal with Aetna...after your final appeal you go to an outside appeal which I believe is the State....then they will review and make a decision. Don't give up the fight...take it all the way up. I'm right behind you getting ready for the 2nd appeal.

[Sherri A]

My second level appeal was denied....but not giving up.

[Abby-Dabby-Doo]

Sherri~
I have some wording for you regarding the "experimental" wording they are giving you. I'm currently under an appeal also (with a different insurance).
When I get home from work I will post it for you. I don't have my paperwork with me at work.

[moco89]

AETNA has a new cgms policy as of 6/20/08. It actually has a protocol for granting long-term cgms use.

http://forums.childrenwithdiabetes.com/showthread.php?t=18196

[Abby-Dabby-Doo]

http://health.groups.yahoo.com/group/diabetescgms/

ok, i hope this one works....


I've joined this group and I've looked and looked for info regarding appeals... Am I looking in the wrong spot, because I'm not seeing anything?

[Mama2H]

Look in the files section on the main group. Let me see if I can find a link...

Try this:
http://health.groups.yahoo.com/group/diabetescgms/files/

[jane1218]

July 1 2008 Aetna has changed their cgms policy

[Jeff]

What is the new policy?

[Mama2H]

Jane, what have they changed? Would you mind posting a link to the policy or what you know of it :D

ETA: sorry, posted same time as Jeff :o

[jane1218]

According to my minimed pump rep Aeta started approving CGMS 7/1/08. She said it would take about 2 weeks to get the system for my daughter. I will let you know what happens. I will look for the link on Aetna's site and post it later.
Jane

[jane1218]

http://www.aetna.com/cpb/medical/data/1_99/0070.html

[Kaylee's Mommy]

is aetna part of the blue cross blue sheild insurance?