Fighting the insurance company

[Kaylee's Mommy]

I want a real time sensor system for Kaylee.. they are currently unavailable to her through insurance (and her endo really) I want to start pushing for it.. its been almost a year since they were aproved for adults..I think this is something Kaylee can really benifit from.. she use to feel her lows in the 60s (occassionally,sometimes not at all) and now she isn't noticing them until the low 40s and sometimes the low 30s.. 33 has been her lowest and its scary.. idon't want to see her there again..

so for those of you how fought your insurance company or endo.. how did you start.. should I start with the endo to convince them this is something that Kaylee needs.. her next appointment is in feb.. I think I'll bring it up then.. but what should I start doing now..

Also, I've heard they are coming out with a smaller sensor.. kaylee is on the minimed 522, so the minimed CGMS is what we'd be going with..


thanks!:)

[rmccully2000]

Kim,

You really need to convince the endo first to write you a prescription/letter of medical necessity. Jeff has some links up to different studies here:

http://www.childrenwithdiabetes.com/continuous.htm

The most recent one was a study of MM in the Dec. 2006 issue of Diabetes Care.

Once you get an endo to agree to write a letter of medical necessity off-label for under 18, then you have two options.

1. Buy the system yourself and file the insurance claim to seek reimbursement. THis is risky since it's possible you could lose and not get any money back. However, you will most likely have conclusive data that CGMS can reduce severe glycemic events and reduce glycemic excursions after using the system for a month.

2. You could submit the letter of medical necessity to your insurance's predetermination department and fight the battle before spending any money.

I have posted some links and documents in the files sections of they Yahoo CGMS users group for help with getting insurance coverage. I also posted the Explanation of Benefits from United Healthcare showing that the Dexcom sensors were a covered benefit (first try, no appeals THANKS AGAIN AMY!!).
This could prove to your endo that insurance providers are covering CGMS for kids off-label.

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

If you decide this is something you want to pursue right now, good luck!!

Becky,
Mom to Mason, 6

[Kaylee's Mommy]

Thanks for all the information.. I'm now confused.. the sensor you have to replace every year because you can't change the battery.. I hope MM is working on this issue.. that just seems like a waste, to have to replace that device everyyear.. Ican see a fight on my hands now..

[rmccully2000]

That's a good questions about R&D. You know, I haven't heard from either Dexcom or MM whether they were working on putting replacable batteries in the transmitter (and the receiver for the Dexcom). I haven't thought that far into the future as far as insurance. I guess I always assumed that Navigator would be available (with replaceable batteries) and I wouldn't have to worry about that.

But, the answer to this argument from insurance is to show them a cost comparison between one hospital stay and a year;s worth of CGMS supplies. Our diagnosis bill for Mason was around $12,000 (this was the negotiated rate), 3 night stay in the hospital (no picu). It would be more expensive if an ICU stay is required for a severe glycemic event.

Becky

[wendyc]

The Joslin in Boston received a grant to study CGM. I read about it in the latest issue of the JDRF magazine. Can you work with your endo to possibly piggyback onto that? It could possibly at least get your foot in the door and show how much your child needs it.

It frustrates me that we have to "fight" for this. It is another important tool that will keep our children out of the hospital, thus saving the insurance companies money. Will they ever get it?

[Rhonda]

I talked to mm last week about getting Lilly a cgms they told me they are workin on one specifically for children right now and will be available after the new year

[5miraclez]

I'm trying to get me on a MM CGMS first since they are approved for adults. Once I do that, then I will fight to have my dd on one. I was told they are working on one for kids, or rather the needle will be smaller on it so kids can use it and was told 3 months out.

[EmmasMom]

Hey Kim,
I agree with Becky that you must get approval from the endo first. I had to present a letter of medical necessity to our insurance from our endo saying why Emma needed it, so he had to be on board. It also requires a Rx before you can place an order or seek coverage.
I would print out all of the latest research and discuss it with your endo. Some are more open to it than others, so be prepared for possible negativity about using it on small children.
I made it clear to Emma's endo that I knew I would still be doing finger sticks, that it was going to be $$$ if we couldn't get coverage, and that there was a chance we wouldn't like it. I think many endo's are worried that you'll stop testing enough, or have expectations that are way too high. I wanted him to know that I had done my research and knew what I was getting into!

I really hope it works out!! BTW it has blown away our endo's expectations!!;)

The transmitter is only under warranty for 6 months, and has an expected lifespan of 9-12 months. I'm not too concerned about it because I'm hoping to upgrade to the next generation by the time it dies. If you get one now you may have to purchase a new transmitter in 6-12 months either way, so you'll just have to decide how long you're willing to wait.

[hrermgr]

We are going to go for a MM BG sensor soon. Our endo office already provided us with a letter of medical necessity! My husband has spoken with MM and they have given us steps to take with the insurance company and referred us to some websites to help us. So far we feel good about Teagan's chances for getting a sensor, especially since our insurance company has approved the use of one in another child at our endo clinic. But, you never know....we're also getting a pump after the first of the year and perhaps the insurance company will not want to pay for both.

For us, it's at least worth a shot to get insurance to cover it. The worse thing they could say is no. I wouldn't even mind if our using it with Teagan was part of study for kids use. I think that would be great.