BCBS and CGMS

[jules12]

Well....after talking with the doctor at the last appointment, he suggested cgms for my son. So I called minimed over a week ago to try to get the ball rolling - they said they could not work directly with my insurance and that they have contacted the endo doctor's office to get a letter from him to "authorize" not sure that was the right word used - anyway, I questioned further as to who would get this letter and she said the doctor would send it directly to the insurance company. Therefore, I called the doctor's office to tell them that I definitely would be needing a letter.

I guess my question is to those who have been down this path - what next? Hopefully the doctor will copy me on the letter but with the pump, I never saw any of it.

I tried to find out from the insurance company but they couldn't even find cgms in their system - they only found the codes for the three day blind option after I gave them the codes. Hopefully, I will hear from the dr soon about the letter he is sending and then we can get to work fighting the insurance! It's just frustrating because you cannot seem to get a straight answer from insurance or minimed regarding the process.

[Paige's Dad]

You have a procedure to go through with BCBS. First, have your endo send a prescription and a letter of medical necessity to BCBS and to Medtronics. If they approve it, all you have to do is wait for it. If they deny it, then we can help you with appeal letters. If it is denied for being "investigational", I can send you a copy of a great letter that Rick helped draft for us that caused them to overturn the denial. Good luck :)

[KitKat]

Good luck! I am fighting BCBS right now. They denied us on investigational/experimental.

I would be interested in the letter you used from Rick to overturn your denial too.

Kathy

[Paige's Dad]

Anyone interested in a copy of the letter, just send me an email at mrockhold@msn.com , ask me in the email to send you a copy of the denial letter and I'll email it right back to you. Be sure to tell me what you're emailing me for, as I receive in excess of 200 emails per day.

[jules12]

You have a procedure to go through with BCBS. First, have your endo send a prescription and a letter of medical necessity to BCBS and to Medtronics. If they approve it, all you have to do is wait for it. If they deny it, then we can help you with appeal letters. If it is denied for being "investigational", I can send you a copy of a great letter that Rick helped draft for us that caused them to overturn the denial. Good luck :)

Thanks so much for responding. I now have the letter of medical necessity but I am not sure the endo sent a prescription with it. So I left them a message today. I figure the insurance will try to deny it but I am prepared - thank's to you - to fight it. I already requested a copy of your letter when you first offered! :)

We will just have to wait and see what happens. If I haven't heard anything in a week, I will start calling the insurance company!

[jules12]

I don't have the official letter yet but I was told by BCBS of Kansas City that we were denied based on the fact that it is a "non-covered service"

Anyone have appeal letter info dealing with that? They are sending me out an appeal form today.

[momofsingingdiabetic]

We have BCBSNC and it plainly says on their website that they do not cover the CGMS, but will be reviewing the technology this summer. If they put it into the policy, we will probably look at one. Danielle has expressed some interest in one even with an extra site....and that surprised me.

[jules12]

We have BCBSNC and it plainly says on their website that they do not cover the CGMS, but will be reviewing the technology this summer. If they put it into the policy, we will probably look at one. Danielle has expressed some interest in one even with an extra site....and that surprised me.

That's just it - it doesn't have it listed at all on anything - at least it didn't when we started - I believe this may have been a change recently. They couldn't even find it in the computers when I called specifically to ask if was covered! I am going to try to appeal - I feel a little out of my element but I figure it can't hurt!

[KitKat]

I think you need to talk with Paige's Dad. He is from Kansas and I believe he just got his denial overturned. Good luck we are going through the same thing right now!! I am so frustrated.

[jules12]

I got to thinking after someone posted above that it states on their website of their insurance that they do not cover CGMS - I decided to look again because I did not find that anywhere - I called the insurance company again - 1) to be sure they mailed me the appeal form and 2) to be sure I had the latest info on what was covered under durable med -- not that I plan to argue policy with them! - she then asked me if I was asking about the denial I received - I said yes and she came back and referred me to the following:

"for any equipment or supplies that condition the air, including environmental evaluations, heating pads, cooling pads (circulating or non-circulating), including hot water bottles, personal care items, wigs, and their care, items for comfort and conveninence, spas, whirlpools, jacuzzis, and any other primarily non-meical equipment, stethoscopes, blood pressure devices, and Durable Medical Equipment that would normall be provided by a Skilled Nursing Facility."

The insurance person went on to say becuase it is a "blood pressure device" it is not covered - I said it is not a blood pressure device - has nothing to do with blood pressure - she said that is what she was told to tell me - I didn't argue with her - I will wait to get to the letter and form a defense for my appeal from there - but thought others fighting me get a little chuckle from that one!

[momofsingingdiabetic]

Here is the link to BCBSNC status on the CGMS. They will be reviewing in May. They have added the codes to this, but it's not a guarantee of coverage. This was originally written in 2006 and it does not cover on basis of it being investigational. We know that's not true anymore, so I hope this gets rewritten in May.

https://www.bcbsnc.com/services/medical-policy/pdf/continuous_monitoring_of_glucose_in_the_interstiti al_fluid.pdf

[jules12]

Thanks for posting - we have nothing like that on any of our policy documents. I am anxious to get their letter so I can really focus on the reason for the denial. I feel like they are just reaching for anything they can.

Our endo wrote a very good letter for medical necessity. Our school nurse offered to write a letter too - does anyone thing that would help as well?

[Paige's Dad]

Here is the link to BCBSNC status on the CGMS. They will be reviewing in May. They have added the codes to this, but it's not a guarantee of coverage. This was originally written in 2006 and it does not cover on basis of it being investigational. We know that's not true anymore, so I hope this gets rewritten in May.

https://www.bcbsnc.com/services/medical-policy/pdf/continuous_monitoring_of_glucose_in_the_interstiti al_fluid.pdf

Our insurance policy says that as well, BUT, since that policy was written, the FDA HAS approved it. That was the entire basis of our appeal, and we DID win with it. Don't wait for them to rewrite policy, that may take years. Appeal and get it done if you really want one. We love ours.

[jules12]

Ok - the girl I talked to on the phone - didn't really know anything. The letter states:

We have reviewed the prior-authorization request for continuous glucose monitoring. Based on Blue Cross Blue Shield of Kansas City's medical policy, a thorough review of the clinicial information provided to us indicates the services not medically necessary as required under the Covered Services section of your health plan because (the sentence isn't finished - it just ends in because)

Payment by Blue Cross and Blue Shield of Kansas City will not be available for this required service. The clincical guideline or scientific medical literature upon which the decision is based is available free of charge upon written request to the Medical Management Division.

It goes on to say that I have the right to appeal.

Any thoughts from guys who have been there done that on what to focus on? Do I have the endo write another letter - submit BG logs, that type of thing to prove it's medically necessary? Would a letter from the school nurse with logs to back up her claims that it would be medical necessary since he also drops as school unexpected?

I would appreciate any help. Thanks.

[jules12]

I am now pulling together information to show that CGMS is medically necessary for my son. The school nurse is writing a letter to show that he does not recognize lows. - I have a call into the endo office to request a new letter from them. And I am pulling log sheets to show the the ups/downs that we experience with very little variance to carb intake or insulin.

Any other thoughts on what else to include?

[jules12]

Another letter from BCBS - this time they are denying it based on it being experimental and investigational. I think I have some good comebacks for that one based on info others have sent me. We will just have to see what happens!