Our First Insurance Covered Sensor Order

[EmmasMom]

Woo Hoo!! I placed an order before Christmas for new sensors, and told them they would need to bill our insurance, (there was a substantial amount of shock in the voice on the other end of the line). It took some time for them to work out all the details w/ the insurance, but today MM called to say my sensors would ship Monday. My upfront cost.... -$0- They said they would bill me for 10% of the negotiated price later.
That means it may not even be the full $35, (for a box of 10) I was expecting! Since we're only using 3-4 sensors per month, (with 24/7 use), our cost is only going to be about $10 a month!!!!!:eek: :D OMG!!

[jacone]

Wow, that is fabulous! I am jealous! When we get to that point I am going to have to learn all your tricks!

Has anyone with BCBS gotten insurance approval for the sensors yet?

[EmmasMom]

Wow, that is fabulous! I am jealous! When we get to that point I am going to have to learn all your tricks!

Has anyone with BCBS gotten insurance approval for the sensors yet?

Unfortunately UHC is one of the few companies that has allowed coverage for sensors so far, and we are one of the first to get coverage on the MM sensors.
The people I have talked to that have BCBS have been told there is no coverage available at this time.:( But I would go through the appeals process anyhow. You just never know who might be the first one to win!!!!

I'm very hopeful that this will change in the near future and everyone will get coverage easily!

[bkfkmc]

Amy-

Congratulations! That is so exciting to know they are actually paying for it. I faxed my first official plea last week to Cigna. My son's Endo didn't sound very optimistic, but I have to at least try. Like you said, someone has to be the first they say yes to. I found out too late (after enrollment) that one of our insurance options was being bought out by United Healthcare. If I am not successful in obtaining coverage from Cigna, I guess we will try changing insurance to United next year. Thank you for sharing all your success and information.

[rmccully2000]

AWESOME!!! Congrats Amy. You worked hard for it and it paid off, literally.
Becky, mom to Mason, 6

[EmmasMom]

Amy-

My son's Endo didn't sound very optimistic, but I have to at least try. Like you said, someone has to be the first they say yes to.


No one was optimistic that we would get covered either. Not the endo, or MM!
I'm keeping my fingers crossed that Cigna will come through for you guys!

[BrendaK]

Amy-

Congratulations! That is so exciting to know they are actually paying for it. I faxed my first official plea last week to Cigna. My son's Endo didn't sound very optimistic, but I have to at least try. Like you said, someone has to be the first they say yes to. I found out too late (after enrollment) that one of our insurance options was being bought out by United Healthcare. If I am not successful in obtaining coverage from Cigna, I guess we will try changing insurance to United next year. Thank you for sharing all your success and information.

Please let us know how it goes with Cigna -- that's our primary insurance, too.

[bkfkmc]

I will certainly keep you posted. Thanks to the information that both Becky and Amy have provided, I will appeal if they first say no. But Becky also pointed out to contact Human Resources of the work that sponsors the plan if it is self-funded. I believe my husband's is self-funded, so that will be my next course of action. I am just keeping my fingers crossed that none of my activism will be necessary!

[bkfkmc]

Well I got the dreaded letter today in the mail. Cigna denied my initial claim. The funny thing is that I was expecting the denial but I was unexpectedly upset anyway. It just hit me the wrong way when I read that it was denied due to CGMS being considered experimental, investigational, or unproven. It will be really difficult to appeal this with the company. What does it take to "prove" it? Braden has been wearing this since November and it has "proven" itself over and over to us. I decided not to try to start on an appeal for a few days to allow my emotions to calm. I generally am very logical and control my emotions, but something about reading the letter just hit the right spot I suppose. Anyway, I need to be back to my logical self before attempting the appeal. I just thought I would give an update.

[hold48398]

Hey Amy, I couldnt be happier for you and Emma!!!:)

[rmccully2000]

Well I got the dreaded letter today in the mail. Cigna denied my initial claim. The funny thing is that I was expecting the denial but I was unexpectedly upset anyway. It just hit me the wrong way when I read that it was denied due to CGMS being considered experimental, investigational, or unproven. It will be really difficult to appeal this with the company. What does it take to "prove" it? Braden has been wearing this since November and it has "proven" itself over and over to us. I decided not to try to start on an appeal for a few days to allow my emotions to calm. I generally am very logical and control my emotions, but something about reading the letter just hit the right spot I suppose. Anyway, I need to be back to my logical self before attempting the appeal. I just thought I would give an update.

I'm sorry you have to go through this but I think you can get around this one.
1. MM has had a CGMS system approved by FDA since 1999.

http://www.fda.gov/cdrh/consumer/mda/

Search the PMA database (http://www.fda.gov/cdrh/consumer/mda/) at the FDA with applicant name "minimed". Page all the way back to the very earliest result, in 1999 (Continuous Glucose Monitor, PMA number P980022). Print this out and send it in with your claim as proof that this technology is not new and experimental.

2. Medicare has CPT (doctor's fee codes) and HCPCS (device codes) for continuous glucose monitors. Print out these codes and attach them also.

CPT codes: I found these on the AMA (https://catalog.ama-assn.org/Catalog/cpt/cpt_search.jsp)site:

https://catalog.ama-assn.org/Catalog/cpt/cpt_search.jsp

95250. Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for up to 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording

95251. Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for up to 72 hours; physician interpretation and report

HCPCS Codes: (http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp#TopOfPag) (these are not exactly like the recently released but very similar to prove that it's not new technology)

Select the 2007 file to download and view the excel spreadsheet:

Code S1030 'CONTINUOUS NONINVASIVE GLUCOSE MONITORING DEVICE, PURCHASE '

Code S1031 'SENSOR REPLACEMENT, AND DOWNLOAD TO MONITOR

3. Not Investigational or Proven:

a).There have been alot of recent studies. I believe Jeff keeps the list pretty current on this page (http://www.childrenwithdiabetes.com/continuous.htm): Print these out and fax them in with your appeal.

There were also a few more... one in the Dec. issue of Diabetes (http://care.diabetesjournals.org/cgi/content/full/29/12/2730)care and this one from BD (http://www.bddiabetes.com/us/main.aspx?cat=1&id=2968)

You could even print out ones for other systems to show the success in the technology in general. Bring it all around and tie it to the DCCT (http://diabetes.niddk.nih.gov/dm/pubs/control/index.htm). DCCT says tight control reduces the risks of complications but doesn't recommend it for children under 13 because of the increased risk of severe hypos... cgms makes IIT possible while reducing this risk greatly.

b). You have the data to prove it's effectiveness. Print out graphs from the downloads that show situations where Braden would have gone low and you were able to prevent it.

I have an example of the appeal I started but never needed in the files section of the yahoo cgms groups (http://health.groups.yahoo.com/group/diabetescgms/). Feel free to use any part of it you find useful.

Good luck! I know how you feel (though I didn't have this headache for CGMS, I have fought for various surgeries/procedures for another child so I know how frustrating it can be :(

Becky, mom to Mason, 6 using Dexcom

[bkfkmc]

Thank you, Becky for all the time and research you have put into this. I am so glad that you didn't have to use it, but you have given me a great start. I really appreciate your help!

[rmccully2000]

You're welcome :)
Becky

[mariano42]

Unfortunately UHC is one of the few companies that has allowed coverage for sensors so far, and we are one of the first to get coverage on the MM sensors.
The people I have talked to that have BCBS have been told there is no coverage available at this time.:( But I would go through the appeals process anyhow. You just never know who might be the first one to win!!!!

I'm very hopeful that this will change in the near future and everyone will get coverage easily!

Hey everyone-
Just ordered my RTS and 522 pump, and now I am seeing some more insurance issues when it comes to the RTS. I have been told by numerous people that United HealthCare is one of the companies that are allowing coverage to these sensors, but when I call United they swear that it is not possible without insurance codes from Mini-Med. Has anyone here got UHC to pay, and if so how!?!?
I have spent most of my morning trying to find the right person to talk to and have had no luck!

Thanks,

Mark

[EmmasMom]

Hey Mark,

For me it was no easy task! I went through the predetermination department at UHC and was turned down more than once! I continued to appeal their decision and was finally told that they would cover the sensors for my daughter.
There are no billing codes, so UHC has to negotiate with MM on each case individually. They are not covering them for everyone, so far just a few people have managed to get the sensors paid for.
Our claims are *still* waiting to be paid, (lots of red tape), but MM is now billing UHC for our sensors, not us, after I provided them with the letter from UHC saying they would be covered. I'm keeping my fingers crossed that it's going to work out!

Just keep trying!!! Good Luck!