Independence Blue Cross - Now covering CGMS

[Darryl]

Independence Blue Cross of PA just issued a revision to its medical policy 5.00.24d for
Continuous Glucose Monitors. The new revision 5.00.24e now considers CGM's "medically
necessary and therefore approved" for Type 1 diabetic patients who meet 5 seemingly
reasonable criteria.

This new policy refers to "real-time CGMS application in diabetic care." The old policy
stated that the CGM was simply an "adjunct to fingerstick testing and therefore not
medically necessary". It seems like IBC finally gets the point...

Assuming that IBC follows through and actually honors this new policy, I consider this to
be a major victory for CGMS coverage, from a major Blue Cross organization.

The only sticking point I see in obtaining coverage is the requirement for "severe ketosis
or hypoglycemic episodes". Document your BG's well if seeking coverage!

I also want to point out that this study referenced the recent JDRF article that was published
in the New England Journal of Medicine - the article that appeared to conclude that CGM's
were not effective in children due to non-compliance and/or lack of training. It seems that
the policy commitee addressed this issue by requiring certification that the patient was
skilled in self-management, and that the patient received training from a medical professional
in CGMS use.

Following is an exerpt from the new policy. Anyone with IBC coverage may want to revisit
their prior claims.

Title: Invasive Continuous Glucose Monitoring Systems
Policy#: 05.00.24e

LONG-TERM INVASIVE CGMS


Use of a long-term invasive CGMS to measure interstitial glucose levels via a subcutaneously implanted sensor is considered medically necessary and, therefore, covered when an individual demonstrates one of the following criteria:

• The individual is a pregnant female with type I diabetes, or:
• The individual has type I diabetes and documentation of all of the following:
  • The CGMS is prescribed by an endocrinologist.
  • The individual is on an intensive insulin regimen, requiring two or more insulin injections per day, or utilizes an insulin pump
  • The individual has a documented history of severe ketosis or hypoglycemic episodes without experiencing warning and recognition of symptoms (hypoglycemic unawareness).
  • The individual has demonstrated mastery of the fundamentals of diabetes self-management, which includes:
    • Routine, regular testing of blood glucose levels at least three times a day
    • Maintaining accurate records of blood glucose testing
  • The individual has received education and training from anaccredited health care professional to master the CGMS, including all of the following:
    • Basic care of the device (eg, insertion, calibration, expectations)
    • Use of real-time CGMS application in diabetic care
    • Alarm use and problem solving

[sam1nat2]

we have blue cross and they at first covered it and then denied coverage stating he didn't go low enough often enough. Nevermind the highs........

Its a good start though to see companies recognizing the benefuts!

[moco89]

This is GREAT NEWS!!!!!!

I hope you will be able to obtain coverage after all of your hard work and effort with D care and the appeals. You have definitely fought your battle, and this will make your life (and your daughter's) a lot easier.

Thank you for posting this.

Now it's back to studying!

[Darryl]

This policy looks more promising than other's I've seen that require a certain number of DKA's, or
hospitalizations. This seems to allow even hypoglycemica unawareness as a criteria.

We are going to re-apply for benefits and will let everyone know if they honor our request.

[Wendyb]

I have Horizon BCBS of NJ and they have the same five criteria. I submitted our BG's about 10 days ago. Criteria number five says you have to have documentation of the severe lows if the A1c is less than 7%. I'm not holding my breath. I still think it sucks.

[Darryl]

Does the Horizon policy actually say 7%? That is not required specifically in the IBC version.

[saxmaniac]

Wow! Looks like they boarded the clue train, and have crunched the numbers.

As in: CGMS $$ < (ER Visit $$) squared. Duh.

[Abby-Dabby-Doo]

Originally Posted by saxmaniac

As in: CGMS $$ < (ER Visit $$) squared. Duh.

That's a good formula! I wish I would have used that in one of my appeals!