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BCBS Alabama - CGM sensor denial

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

  1. iluvmhp

    iluvmhp Approved members

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    Has anyone had any luck getting Dexcom sensors approved with BCBS Alabama. I have been denied in the appeal process and am desperately looking for advice.

    They are saying she doesn't have enough blood glucose numbers lower than 50. She had several on the logs I sent, but I guess they were not enough! She is also on the system, (previously approved by UHC) so it is working and preventing the higher number she had before.

    We sent a letter from her endo saying it was medically necessary, sent blood glucose logs and a letter detailing how she was currently on the system, thus preventing most low blood sugars.

    Do I have to take her off and let her go low to let them approve it....this is so worng!
     
  2. hawkeyegirl

    hawkeyegirl Approved members

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    Some numbers lower than 50 would "magically" appear on the next logs I sent in. Just sayin'....
     
  3. iluvmhp

    iluvmhp Approved members

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    They were on there....just "not enough" of them. I don't know how many they want? Trying to find that out not. Upsurd!
     
  4. JeremysDad

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    We have BCBS Wisconsin and if I remember, Jeremy only had 1 reading lower then 50. Most were high, very high. Our Endo put Jeremy on the 7 day Dexcom before sending in the application for the Dex...which our insurance covered. Perhaps Jeremy's A1c was all that was needed for approval. His was 11.2.

    I would certainly appeal it. The Dex is a lifesaver...literally!!!
     
  5. Kimby

    Kimby Approved members

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    We have BCBS Alabama PEEHIP and were approved. Jason Haar at Dexcom was the rep who helped us. Perhaps talking to him would help? Good luck with your appeal!
     
  6. fredntan2

    fredntan2 Approved members

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    My rep told us exactly how many lows that was needed each week and how many highs. Made sure what he requested was on there, think it was two a week. Kwim
     
  7. iluvmhp

    iluvmhp Approved members

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    Thank you so much. That is what I am missing - how many they want. I can't get an answer from them. Actually, I am not allowed to talk to the medical advisor. Only her endocrinologist can and they won't return his calls. He has been trying to do a peer review for over a month now.

    We are not giving up. She has been on this system for almost two years now and we just can't go without it. I will try contacting my Dexcom rep again and see if she knows anything else.

    I appreciate the help.
     
  8. selketine

    selketine Approved members

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    Can you continue to appeal?

    I think if this is an employer's insurance plan that sometimes they can be contacted to step in when something is denied but honestly I don't know much about that so certainly research it if there are no other options.

    Completely absurd.:mad:
     
  9. iluvmhp

    iluvmhp Approved members

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    I can do one more "voluntary appeal" and/or file a lawsuit with the federal government. Of course, I have to ask for information in writing in order to do anything else. Which of course will take more time. I have been fighting for this since January of this year! It is almost June. :( UHC approved it for us for the past two years....this is just insane!
     
  10. kimmcannally

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    IIRC, Dexcom told us they would be looking for more than three lows below 50 per month.
    Heck, even with the Dex we still have that many!
     
  11. yelley

    yelley Approved members

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    Anthem Blue Cross CA here

    I went through the same thing. I sent in the appeal and even though I had 4+ lows below 50 in a months time, they still denied it.

    Our endo even called to appeal.

    We had met our out of pocket maximum for the year so it would have been covered 100%..... not sure if that is a factor but who knows....

    I still have about 3 weeks until I reach the 180 days since the denial, I am just not sure I want to keep fighting.
     
  12. bibrahim

    bibrahim Approved members

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    I appealed BCBS Oregon and won. I sent print outs of the dexcom and highlighted the lows in yellow and the severe lows in red. I also sent a letter describing what happens when she is low in her sleep and that she has hypo unawareness. We had some lows show up but not on purpose. There were a few 39's on there and on the print out it looked very significant. I sent in a stack of print outs for the prior 30 days. I also pointed out in the letter that due to the hypo unawareness we did not feel as comfortable with running lower numbers and doing intensive exercise due to her hypo unawareness.
     
  13. iluvmhp

    iluvmhp Approved members

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    Well I am working on the final appeal letter today. I appreciate everyones feedback. Unfortunately, I have provided all of the information in previous appeals that was recommended including a letter from her endo along with calls for peer review.

    I am going to give it one more shot.
     
  14. iluvmhp

    iluvmhp Approved members

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    My second appeal letter was a success. My sensors are now covered at 80%! Thank you all for your advice!
     
  15. emm142

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    Yeah! Congratulations :) I'm glad you kept fighting.
     
  16. bibrahim

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    Great news! It pays to be persistant.
     

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