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Tricare and CGMS

Discussion in 'Parents of Children with Type 1' started by Illinifan, May 23, 2011.

  1. Illinifan

    Illinifan Approved members

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    I've done the searches and can't find a thread on this particular topic.

    Who here has successfully applied for a CGMS through Tricare Prime?

    Which Tricare region are you in?

    Did you get it the first time or did you have to appeal?

    What justification did your endo have to give?

    TIA.
     
  2. CaelinsMommy

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    http://forums.childrenwithdiabetes.com/showthread.php?t=4437&page=2
    There is some discussion about Tricare and CGMs coverage here. Also, if you search just "Tricare" there is an older thread about it. I would search it for you but I have horrible internet right now. We did try to get Caelin a CGMs 2 months ago (Tricare Prime North region) and were rejected. She is hypo unaware and we had to show 2 to 4 instances of a bg under 50. She meets all their criteria but they rejected because of her age. We haven't appealed yet because it was literally a week before a PCS move.
     
  3. mlbg10158

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    This is a puzzle for us, too. Avery has been on the Dexcom for over a year. Now tricare denying future coverage because she's doing to well. Thanks Dexcom for helping her through her 1st 2 years of college! Now what do we do?????
     
  4. BrendaMc

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    We have Tricare North region... my husband was active duty. We only have it through August for free unless we start to pay for it. Our primary insurance turned us down but Tricare picked it up without any hassle. Needless to say we were surprised. Edgepark Medical this week is asking for a new system since ours will be a year old this month. We shall see- we're holding our breath.

    But they have paid 100% this entire year. We are planning to go though our primary insurance again later in the year and if we get turned down, we're going to try to appeal. Our primary insurance is Duke Wellpath, a subsidary of Conventry Health Care.
     
  5. PixieStix

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    We have TRICARE Prime North Region too. Started CGM in 2006--first couple years didn't even try to get covered, paid OOP. Since around 2008 have had costs covered most of the time, sometimes gets denied but so far has gone through after submitting additional supporting documentation/justification from endo. The last time we had sensors denied I spoke w/ a nurse from TRICARE who said they were tightening the parameters to approve coverage. She told me to always have the endo fax BG log/Carelink report highlighting hypo events, esp nighttime events, and any documentation showing hypo unawareness. She said to be sure this evidence is sent in at the same time the Letter of Medical Necessity is submitted to increase odds of approval w/o having to go to battle for CGM every time. Can not imagine DS w/o this--am sure it has saved him from severe hypo events many, many times over as we try to keep BG very tight--would pay OOP if I had to but grateful for TRICARE coverage.
     
  6. roo'smom

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    We're Tricare Prime and in the North region. We just got a new MM (were formally Cozmo users) and CGMS approved in January. So far no problems, but it looks like I should be knocking on wood... Our endo's office (Portmsouth Naval) handled all of the paper work, but we did have to submit 30 days worth of logs. We test almost every two hours at night with no discernible patterns - I don't know if that had anything to do with approval. If you have any other questions feel free to PM me...
     
  7. Illinifan

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    I'll start with a round of thanks...first for replying to my post, but most importantly, being military families. Having served for 21 years, I know the additional stress this must put you under. Zach was dx during the last couple of months I was active duty, so I never had to leave for 180+ days for a deployment and leave my wife alone to deal with it.

    Ok...I didn't say this earlier, but if you looked at my profile you can see that I'm at Wright-Patterson AFB and we are in Tricare North too.

    However, Zach has a permanent off-base referral to Dayton Children's Hospital and sees Dr. (USAF Col retired) Moira Pfieffer. She was the one of the few active duty pediatric endos in the AF and she elected to retire and stay in Dayton. She told Dayton Children's she'd join their staff but only if she could bring her patient load from the base.

    So...I guess what I am saying is that I'm wondering if the oddity of having an off-base endo will screw up the process for getting a CGMS approved.

    Having lived with military healthcare (on-base, CHAMPUS and Tricare) for 27 years, I'm pessimistic about this. Hopefully, I'll be proven wrong.
     
  8. PixieStix

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    My scripts for replacement CGM and sensors have come from a civilian peds endo since we moved to OH. The original prescriptions were written by a military pediatrician. I don't think military/civilian status of doc will impact approval, but definitely need documentation to support hypoglycemia, even stronger justification if you have documented incidents of hypoglycemic unawareness. I do find that I have to REALLY push to get any documentation sent from the endo office along w/ the Letter of Med Necessity though, usually the technicians are resisting that extra forms not needed but then I am the one on the phone figuring out why the sensors were denied this time...

    p.s. We saw Dr Pfieffer once at at WP before she retired. Originally thought we'd use WP for our medical care, but just too far so forced us to figure out civilian healthcare system.
     
  9. Saniyah's Mommy

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    We are about to put our 20 month old daughter on the pump and CMG. Our endo actually recommended that we do this. We currently have tri care west and our endo said it won't be a problem for us to get. She's actually going to put in the order herself to make sure she handels any issues that may come up personally. It will cost us nothing, Tri care handles it all. I would talk to your endo and see if there is anything they can do.
     
  10. BrendaMc

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    We've never seen a military physician so I dont think that matters.
     
  11. Illinifan

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    Just talked to my wife and she talked to a Tricare person today and he told her that the paperwork was all in order and that we'd be hearing from them soon. Keeping my fingers crossed.
     

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