Ugh

[zimbie45]

So we have gotten denied for our cgms.. as " experimental".. Im so frusterated right now because aetna says they cover it for all diabetic that have hypo unawarness. BUt they say that i can appeal it.. im wondering if they say experimental due to her age.. she is 6 and will be 7 in 1.5 months.. SO i think that i will be waiting till them to appeal it so they cant say " experimental" UGH...

[BrendaK]

Let me know what happens and why they denied it -- we are getting Aetna in January. Carson is 7, so maybe they would cover him??? Our Durable Medical is covered at 100%, so if it would be totally free, then I'm in...

[zimbie45]

ill keep you posted.. I have a feeling that is way because she is not " 7" yet.. BUT who knows.. Im going to wait for my offical denial. THen im going to fight it with a letter of medical necessisty from the doctor, and wrtite my own letter too.. Ill keep you updated

[nantomsuethom]

We have aetna. I called last month to see if they are covering them yet and they said no. I asked if they will be covering them in the near future and she said she wasn't sure.

I just did the math for strips we use now vs. sensors and strips if we had a cgm.
Thomas tests between 10 and 15x a day. Aetna pays $884+ every 3 months for 1100 strips.
If we had a cgm they would only have to pay for 400/450 strips every 3 months which I figured to be a $560 - $600 savings in strips. The sensors would be about $650 for 3 months.
I am going to submit this to see what they say.

[Val]

We have Aetna as well. Simon is 3 1/2. Their "experimental" denial is just a standard thing they do. I have heard that they have approved on a case-by-case basis, namely if there is Hypo-unawareness. Well, having said that...we had Simon wear the diagnostic thing for a week to gather data. Then his endo wrote a letter with all kinds of details documenting the fact that we needed it for hypo-unawareness. Wouldn't you know we got denied, because they only cover these things for patients with hypo-unawareness!! :mad: Did they even read the letter?!! This has been very frustrating, as we can not seem to get anyone on the phone that even has a clue. I have another (our third) appeal in, so hopefully we will get somewhere with this. Wish me luck!!

[bkfkmc]

I wish you the best in your fight with Aetna. I do want to let you know that Cigna denied us for the same reason, experimental and investigational, and Braden is 7. Cigna does seem to be the worst at covering anything though. More luck to you!

[zimbie45]

Ah but they do cover them.. tehy even have it posted on there website..

Go to aetna.com
click on members public information
click on health coverage information.
click on clinical policy bulletins
click on medical
clikc on i accept
click on alphabetical list
click on d for diabetes and scroll down to Diabetes Programs and Supplies- CPB-0070 and click it.

#7 vii says
Continuous Glucose Monitoring Devices:

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:

repeated hypo- and hyperglycemia at the same time each day; or
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 for home self-monitoring of blood glucose experimental and investigational.


hope this helps anyone

[BrendaK]

So are they seriously saying they will only pay for 6 days out of the year? They would pay for the whole system, then only 2 sensors? Or something like that... That's quite a "waste" of money if you ask me...

[zimbie45]

its all very confusing if you ask me.. Most of the reps have no clue what it is you are talking about.. Then they say they do cover them at 100% for hypo unawarness.. ( which is one of the reasons er admitted charlize in may) whick is what aetna paid for,....

[Wendy12571]

Hi Everyone,
Okay Aetna is claiming they will only cover the CGMS's like the used to cover the blinded minimed thing. Before all the new technology came out their was the blinded test. Basically they are saying they will cover whatever one of the systems you want to use for 6 days if you meet the following problems. Otherwise you ain't getting it covered.

[bkfkmc]

Just to add to Wendy's post. This is similar wording in Cigna's plan as well. It is referring to the CGM that is for in-office use. This was used long before it was available in the form we have now. It was inserted in the office and you were not able to view the numbers yourself. Rather, you went back to the office and the dr. downloaded the information. You would wear it for 3 days. That is why it states two 3 day periods. Hope this helps (not really, but you know what I mean.)