Getting Insurance Company Approval

[Jeff]

For those of you who have succeeded in getting insurance company approval for continuous glucose sensors, I would like to know:


What did you provide by way of blood sugar data?
What data did you or your doctor need to provide to support the use of a continuous sensing system?
Can you offer any tips to others who are seeking insurance coverage?

[rmccully2000]

I'm going to preface this with the note that Amy (Emma's Mom) probably paved the way for us at United Healthcare since she showered them with information in her appeal!

1. What did you provide by way of blood sugar data?

Nothing

2. What data did you or your doctor need to provide to support the use of a continuous sensing system?

Nothing, just the prescription.

3. Can you offer any tips to others who are seeking insurance coverage?

Find out if your employer has a self-insured policy. If they do, your employer has final say over any decisions made by the insurance company. Make your appeal to the employer if the insurance company denies your claim.

Show the insurance company a cost comparison of any hospital visits, ER visits, etc for severe hypo or hyperglycemia (including any costs incurred at diagnosis if you can get it). One trip to the ER is about equivalent to a year's worth of sensors. Remind them that insulin has dangerous side effects that can result in expensive medical care.

Do NOT talk about convenience, happiness, or how the unit will make life easier for you/your child. DO talk about medical necessity and reducing side effects and complications. They are a business and they have to make a business decision, which unfortunately for the consumer doesn't take happiness into account.

Medical necessity is there for anyone taking insulin, regardless of age or A1C. Accurate adminstration of insulin is grossly inadequate with fingerpokes alone. Continuous reading paints a more accurate picture with direction and rate of change. With a CGMS you will make more informed decisions regarding therapeutic adjustments with insulin and carbs.

That's all for now, though I could probably go on if you (and the kids) would let me!

Becky,
Mom to Mason, 6 Dexcom since October, covered by UHC

[payam7777777]

Becky (rmccully2000) has also uploaded useful info/files here :
http://health.groups.yahoo.com/group/diabetescgms/
about insurence.

[EmmasMom]

Becky, did you give them a HCPC code?? I seem to remember you saying that you found a billing code somewhere that could be used. This was our biggest struggle! There is no actual billing code for the insurance to reimburse for these new con mons, so they fought me endlessly about getting one. I found some codes for one time use, (when your endo hooks you up for a few days), but that's all I ever saw. I still can't believe they covered yours w/o a fight!!! Amazing!!

Because of the lack of a code United Health Care had to negotiate reimbursement with MM on a "Sinlge Case Negotiation Basis". I used this exact wording in my final letter to them, and it seemed to do the trick.

We presented a letter of medical necessity from Emma's Endo, stating that her A1C was higher than he'd like, (we happened to have our worst A1C ever this summer, 9, so it worked in our benefit) and that she was very difficult to manage. This was the only medical info they asked for, no blood sugar logs or anything like that.

I wrote a letter detailing her hypo unawareness, inability to communicate well about how she feels, history of hospitalizations, need for very frequent finger sticks, etc. We basically outlined why she is in so much danger, and how much it could cost them.
We also prepared a spread sheet of cost comparisons between frequent testing or CGMS with less frequent testing. It proved that this would actually save them money in the long run, and would never cost them more than testing 10-12 times per day.
I also provided clinical trial results and information sheets about the device we wanted, so they would know exactly what we were talking about.

It took a few months and two appeals, 20+ phone calls, about 10 faxes with all the info above, and numerous people telling me it could *not* be covered because of the billing code issue, but finally we got the letter saying coverage was available!!!:D

I agree completely with Becky, keep letters about facts and business. They don't care how happy you are, they care about potential cost vs potential savings (keeping you healthy).
I also think that if the government would issue a billing code for reimbursement this would all be much easier!!

[rmccully2000]

Becky, did you give them a HCPC code?? I seem to remember you saying that you found a billing code somewhere that could be used.

Ah, Yes, I did refer them to the "similar" code (I didn't want to be accused of fraud!) It is

S1030 Continuous noninvasive glucose monitoring device, purchase

Dexcom is recommending its customers use these miscellaneous codes:
E1399 is for the Starter Kit and A9900 is for the
sensors.

E1399 DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS Durable medical equipment

A9900 MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS Supply/accessory/service

Oh, another thing I forgot. With the original invoice, I submitted a copy of the Dexcom website that describes what is is and why it's important. Make sure you add the company mailing address and phone number because it is not listed on their invoice. I will call the benefits advisor at Dexcom and ask if they can fix this.

They wanted the provider Tax ID also: 330857544

And the ICD9 code (Diagnosis code) You can get this from your endo. I believe mine was 250.8 which was type 1 diabetes, uncontrolled

Becky

[Adinsmom]

Was the cgm and sensors covered under the "durable medical" part of your insurance?

Thanks for all your help Amy and Becky.

[EmmasMom]

Was the cgm and sensors covered under the "durable medical" part of your insurance?

Thanks for all your help Amy and Becky.

Yes, the transmitter is covered under DME, and the sensors are "disposables" just like infusion sets.

[rmccully2000]

Yes, the transmitter is covered under DME, and the sensors are "disposables" just like infusion sets.

Yes, ours were also considered DME :)
Becky