Help! I need links for CGM appeal & companies who cover

[Val]

I posted this on PWD board also, but thought I should put it here as well.

HELP! HELP!

I am in the final appeal process for Simon to get a CGM. Aetna is specifically denying the claim based on it being "experimental & investigational". (nothing to do with medical neccessity) So really we are going for a policy change which is hard to do, but someone has to do it!

What I am looking for is any link that we can find to studies that show that CGM is indeed effective & no longer considered experimental. Also, if your insurance covers it could you just tell me who it is, so that I can reference other companies who are providing coverage.

This has been a long road to get to this point (since April of 2007 ) so this is my final push. Anything you could provide would be greatly appreciated!

Here is what I have so far:
http://medicine.plosjournals.org/per...d.0040069&ct=1

Failure to awaken increases the risk for T1DM patients to suffer prolonged and potentially fatal hypoglycemia.

http://care.diabetesjournals.org/cgi...t/full/29/1/44

We conclude that real-time continuous glucose monitoring for periods up to 72 h is accurate and safe in insulin-requiring subjects with type 1 and type 2 diabetes. This study demonstrates that availability of real-time, continuously measured glucose levels can significantly improve glycemic excursions by reducing exposure to hyperglycemia without increasing the risk of hypoglycemia, which may reduce long-term diabetes complications and their associated economic costs.

http://care.diabetesjournals.org/cgi...ct/dc07-0067v1

Conclusions:Our findings indicate specific sensitivity of declarative memory consolidation during sleep to rather short episodes of mild hypoglycemia. This effect may disable memory processing in T1DM patients prone to nocturnal hypoglycemic episodes and underlines the importance of considering sleep as a critical period in the treatment of these patients.

http://medicine.plosjournals.org/per...l.pmed.0040099

The development of continuous noninvasive glucose-monitoring devices is a promising strategy. Not only can such devices produce a continuous profile of blood glucose levels in order to better adjust treatment, but they also include audible alarms that can awaken the patient before the onset of dangerous hypoglycemia.

I appreciate anything you can add!! Anything that would suggest that Aetna's policy is behind the times!!

[Danda]

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.

Here is Aetna policy I could find. Try to argue the first part: repeated hypo and unawarness.
Also you may try to contact MLH

I was able to get my insurance company to cover 80% of it (Aetna PPO).

and ask for her input.
Hope this will help.

[Val]

WEll, they will approve only two per year for hypo unawareness. We, of course, want continual use.

[jendean]

Val go to the insurance part. I have posted some professional medical journal studies, (the insurance companies may see them as less biased) re: cbgm, and hypoglycemia problems.

I am still fighting Aetna (and bcbs, long story)
let me know how it works out for you.

[Sherri A]

I am also in the final appeal process with Aetna for my daughter's CGMS. Aetna is denying it based on it being experimental…."There is insufficient evidence to support the prolonged use of continuous glucose monitoring devices as an adjunct to home blood glucose monitoring. The potential advantages of adjunctive use of CGM devices in managing persons with poorly controlled diabetes are theoretical. There are no adequate prospective clinical studies in the peer-reviewed published medical literature demonstrating that the use of continuous glucose monitoring devices results in durable improvement in outcomes of individuals with diabetes."

Has anyone been successful in Aetna covering the CGM and supplies? If so, how were you able to get past their clinical policy bulletin denying coverage (other than twice a year).

Thank you!

[Stacey Nagel]

check out and join this group:

diabetescgms@yahoogroups.com

they have tons of files on appeals etc...
and its a great source of cgms info

[Wendy12571]

Please contact Paigesdad. I am sure he has a letter that will help you out specifically with this issue. I will tell him about this link.