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Has Anyone with Aetna ordered CGMS Sensors recently?

Discussion in 'Parents of Children with Type 1' started by moco89, May 5, 2009.

  1. moco89

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  2. ecs1516

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    Monica,
    It sounds like any children having recurring lows that need help from adults or an adult that need help would still qualify the way I read it. It sounded like just for diagnostic would be limited to 2 times during a 12 month period.

    Here is that part from your link.
    Aetna considers the long-term (greater than 72-hour) therapeutic use of continuous glucose monitoring devices medically necessary as an adjunct to fingerstick testing of blood glucose in adults age 25 years and older with type 1 diabetes, and for younger persons with type 1 diabetes who have had recurrent episodes of severe hypoglycemia (defined as hypoglycemia (blood glucose less than 50 mg/dL) with unawareness that required assistance from another person to administer oral carbohydrate, glucagon, or other resuscitative actions) despite appropriate modifications in insulin regimen and compliance with frequent self-monitoring (at least four fingersticks per day). Long-term use of continuous glucose monitoring devices is considered experimental and investigational for all other indications


    But it does go on to say at the bottom that accuracy goes down with time and the sensors have to be replaced every three days. We know that is not true. Big insurance just wants to play it cheap.
     
    Last edited: May 5, 2009
  3. 22jules

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    We got our cgm from minimed at the end of Dec through Health net and it was approved and paid for. Our insurance changed in Jan to Aetna and when we ordered a box of sensors they denied due to it being experimental. I asked minimed to only send when they get approval from Aetna and when I received the letter denying coverage they said they did and would appeal to Aetna. I haven't heard anything so we have stopped using the sensors for the time being until I find out whether insurance is going to pay or not.
     
  4. sneakermom

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    I posted over on the CGM board but this situation exactly happened to us. We tried to refill an existing order for sensors tonight and were denied based on the document that you mentioned. My endo reviewed the paper put out by Aetna and said that it would be difficult to change her ICD code to one that fit the criteria since she hasn't had a "severe hypoglycemic event" requiring glucagon or gel. I'm glad you asked the question on the main board because I was just about to do that. I livid about this and will be on the phone a lot tomorrow trying to get to the bottom of why they have changed this (without notifying me). I had to find out when trying to place a refill. I have a few choice words for Aetna right now.
     
  5. jbsmom

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    I have the same problem also. United health care approved the cgms in Dec. 2007. The company I work for changed to Atena in January of this year. Tried to refill her order and got the same reply that she was doing great and did not need the cgms. I have been fighting them since the end of March. Still awaiting reply on our appeal. Good luck on your fight.
     
  6. selketine

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    And let them know she is doing SO much better since she started insulin so she doesn't need that anymore either.:mad:

    I don't have Aetna but I find it ridiculous that insurance companies put those restrictions of severe hypoglycemic episodes in order to get a CGMS.
     
  7. Rick_L

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    I have fought Aetna for almost a year on coverage!! Same story about being experimental!! After numerous apeals by me and dexcom, I gave up. I just purchase when we fill the need to do extra montoring:(
     
  8. fredntan2

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    I'm about to put in my order for a dexcom. getting all my stuff together.
     
  9. Kaylesdad

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    Just got mine from aetna last week, it was put in about a month and a half ago by minimed and we didnt have a problem. We have had hypo's but none requiring glucagon. Their wording of "oral carbohydrates" is great though, it is a technical word for "food or drink"
     
  10. AmyMcCracken

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    My daughter was approved by Aetna at the beginning of April. We had to provide blood sugar logs that showed lows under 50.
     
  11. sneakermom

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    I have contacted government relations over at JDRF to notify them of this new document and the trouble that some of us are having obtaining coverage for products that they once paid for. They specifically site the JDRF study in that Aetna document, but it appears very twisted in how they read it. I wanted to make sure that they were aware of this. I'll keep you posted if I hear anything.
     
  12. 22jules

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    Thanks for the update! Look forward to what you find out.
     
  13. sneakermom

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    Okay...so not so happy about JDRF's response.

    I received an email from the advocacy team. They say the new policy is broader and are PLEASED that they broadened it! They said they were fully aware that the new policy document is covering adults over 25 years of age and also covering those under 25 with severe hypo.

    Umm, if it truly broadened the number of people being covered, then why did my daughter lose her coverage? I guess she's not "severe" enough. And too bad for her that she's not 25. We all know how great 4 year olds are at identifying and treating their own lows.

    Thanks for the support JDRF.
     
  14. Deannas mom

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    What about the fact that the CGMS is also used to detect HIGHS????:cool:

    It seams that the Insurance never even thinks of that
     
  15. sneakermom

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    Or the quality of life of caregivers who don't have to set that 1 am alarm. Having the CGM has allowed me to get some decent nights' rest. (When it's not waking me up to tell me she's high or low).
     
  16. Ali

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    One possible thing to try. Look at her last three months of CGMS data and spot three times where she dropped under 50 on the graph. You can show especially if at night that without the CGM her low would have been undetected and would have required a shot or trip to the ER. As it was you could show that you responded to the alarm (and not her to other warnings of a drop) and you provided emergency care. If any of the below 50's were at night it makes your case even stronger. It does not matter if it alarms and you treated and then it went down to 50, she still dropped to that level.You and your Dr. could submit that data with a letter from him and it might do the trick. Good luck.:cwds:Ali
     
  17. sneakermom

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    Thanks, I've been working with my endo on this all day. I can't figure out why she is hesitant to change the diagnosis code so that we can start getting the sensors again. I have given her several examples of <50 readings (pre-CGM). To me, hypoglycemia unawareness or lack of a parent's ablity to detect a hypo should consistute a "complication". That's the hang-up word I'm trying to get them past. She is currently diagnosed 250.03 "diabetes mellitus without complication uncontrolled". If they change it to 250.83 "diabetes mellitus with complications uncontrolled" we get our sensors covered. Hopefully, the endo will come through with this change.
     
  18. jbsmom

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    Aetna wants more proof that Janelle is hypo unaware. I have turned in the last 2 months of pump logs and her last two months on logs while she was wearing the cgms. She has had numerous lows in the low 50's for the last 3.5 weeks. I guess I,m just not letting her go low enough before I make her test. the fight will go on. Boy I sure hate this insurance bureaucracy. Good luck on your fight. We must press this issue and win for our children.
     

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