Has anyone with Aetna (NY) been approved?

[Ellen]

HELP!

My friend was just denied a cgms from Aetna today. Aetna continues to claim the MM CGM is experimental and investgational.

Some of the language in the letter is as follows:

A charge for a service of supply is not covered to the extent that it is determined by us to be experimental or investigational

A medical policy admin medical director board certified in internal medicine has reviewed your request, including all supporting documentation submitted to date.

After this review we have determined that the proposed medtronic minilink transmitter and system are not eligible for payment

Aetna considers the long term use of cgms medically necessary as an adjunct to finger testing of BG in persons with type 1 who have had recurrent episodes of hypoglycemia

Long term use of cgms are considered experimental and investigational

While this response indicates services would not be payable we want to emphasize that the member and physician make the final determination whether the proposed treatment is performed

Has anyone overcome this?

Thanks.

[BrendaK]

That's discouraging!! They are using the language in their new policy that states it IS medically necessary for type 1s with hypoglycemia, but they are STILL denying it. What dirty rats :mad:

[moco89]

Aetna's "official" policy
http://www.aetna.com/cpb/medical/data/1_99/0070.html

Aetna considers continuous glucose monitoring devices (e.g., MiniMed Continuous Glucose Monitoring System, Guardian Real-Time Continuous Glucose Monitoring System, and the DexCom STS), which are used to continuously monitor diabetic persons' blood glucose levels over a three-day (72-hour) period, medically necessary for persons with type 1 diabetes who have either of the following problems in controlling blood glucose level, unresponsive to conventional insulin dose adjustment:

1.
repeated hypo- and hyperglycemia at the same time each day; or
2.

hypoglycemia unawareness.

No more than two CGMS monitoring periods are considered medically necessary within a 12-month period.

Aetna considers the long-term use of continuous glucose monitoring devices medically necessary as an adjunct to fingerstick testing of blood glucose in persons with type 1 diabetes who have had recurrent episodes of severe hypoglycemia (blood glucose less than 50mg/dL) despite appropriate modifications in insulin regimen and compliance with frequent self-monitoring (at least four fingersticks per day). Long-term use of continuous glucose monitoring devices are considered experimental and investigational for all other indications.

You just have to have some below 50 readings to get it. I think it's quite ironic because, if you have hypoglycemia awareness you could miss the below 50s very easily.

[jane1218]

Aetna changed thier policy on cgms July 1, 2008. My daughter's endo put the request in to Aetna July 8. The doctor wrote a letter of medical necessity. The minimed rep called to let me know that Aetna will take 2 week to make a decision on whether it is necessary in my daughter's case. I posted the link to Aetna's policy on this board a couple of weeks ago, but I am sure it is buried in a thread. I will post as soon as I know the outcome.

Here is the link:
http://www.aetna.com/cpb/medical/data/1_99/0070.html

Jane

[Marcy]

How can they STILL say that? When I called MM to get the process started w/ Aetna (AGAIN), they took all my info, asked for at least 2 months worth of bG readings and asked specifically if I had more than 5 episodes below 50 per week. They said they would send it in to Aetna for Predetermination and that it would take "2 weeks." It has only been one week.....I am really hoping this goes through!

Did your friend submit bG readings with her request?

[Momto4]

HELP!

My friend was just denied a cgms from Aetna today. Aetna continues to claim the MM CGM is experimental and investgational.

Some of the language in the letter is as follows:

A charge for a service of supply is not covered to the extent that it is determined by us to be experimental or investigational

A medical policy admin medical director board certified in internal medicine has reviewed your request, including all supporting documentation submitted to date.

After this review we have determined that the proposed medtronic minilink transmitter and system are not eligible for payment

Aetna considers the long term use of cgms medically necessary as an adjunct to finger testing of BG in persons with type 1 who have had recurrent episodes of hypoglycemia

Long term use of cgms are considered experimental and investigational

While this response indicates services would not be payable we want to emphasize that the member and physician make the final determination whether the proposed treatment is performed

Has anyone overcome this?

Thanks.

This is the EXACT response I received about 6 months ago from Aetna. My daughter had a severe low (23) this weekend, she passed out, glucagon was given, 911 was called, etc. So, first thing Monday morning I called Minimed and ordered the CGMS. The rep reviewed my old information and told me that Minimed had just signed a contract with AETNA within the last month or two so it should be easier to get it approved (we'll see!). Anyway, he told me that a rep from AETNA should be calling me within 2 business days to get some more info and review the coverage of the system. So, we shall see. I will post any additional information as soon as I hear from AETNA.

[BrendaK]

I'm just starting the paperwork for the Navigator and we have Aetna. And I noticed that they only specify Minimed and Dexcom :( We're up against a monster I feel like!

[moco89]

I'm just starting the paperwork for the Navigator and we have Aetna. And I noticed that they only specify Minimed and Dexcom :( We're up against a monster I feel like!

Just try playing your cards as much as possible to get approval for the Navigator. Keep on trying, they WILL eventually "figure it out".

[jane1218]

It said...

"A medical policy administration medical director, board certified in Anesthesiology has reviewed your request, including all supporting documentation to date. After this review, we have determined that the proposed Medtronic Minimed Paradigm Real Time CGMS is not eligible for payment. Aetna considers the long term use of cgms devises medically necessary as an adjunct to fingerstick testing of blood glucose in persons with type 1 diabetes who have had recurrent episodes of severe hypoglycemia (LT 50 mg/dl) despite appropriate modifications in insulin regimen and compliance with frequent self monitoring (at least 4 finger pricks per day)"

1) Why was this reviewed by an Anesthesiologist???
2) How many episodes does she have to have?
3) We test between 8 and 15 times a day...

My downfall is I am a terrible record keeper. So I have data a few weeks at a time. When I review her numbers I write them on a scrap papers and make adjustments, then loose the paper. I try to down load her meter and pump, but then she lost her pump uugghh. so I am missing a few weeks of data. I have hope though, I seem to always be able to pull something together. I am now off to search for all those stupid scraps of paper...

My goal is to have the cgms before school start in September.

Jane

[Marcy]

I just received the letter today. It states:

Although there is no documentation of attempts to manage this patient's glucose swings with insulin dosage adjustments, based on the nocturnal hypoglycemia, I will authorize the use of the CGM for this patient.

I can't believe it!! This was my Second Level Appeal. I sent in 3 months worth of bG readings. (Low was 22, high was 574) I had 7 readings of below 50 during the night. With the other letters, I did not include bG numbers, so my guess is that is what swayed them. If anyone would like to see my Excel log (or my appeal letter) I'll be glad to forward it--I copied the log from someone on TuDiabetes.

WOW--The 7 month long fight was worth it!!!

Marcy:)