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CGM Denial

Discussion in 'Parents of Children with Type 1' started by HanksMom, Nov 2, 2012.

  1. HanksMom

    HanksMom Approved members

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    We have been trying to get a CGM approved for our son, who is 3. It was initially denied due to "lack of medical necessity for his age group" and then subsequently denied even after a MD to MD peer review with our endo and the Medical Director for the health plan, still due to a "lack of medical necessity."

    Does anyone have any advice for overcoming this obstacle and convincing an insurance company that this IS a medically necessary device??

    So incredibly frustrated right now...
     
  2. buzco

    buzco Approved members

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    Hi Kim,

    Of course it's a medical necessity (but they have very different logic). They're looking for close calls, or bad lows especially in the night. Have you caught some nasty low numbers? Or god forbid, has your child had emergencies (not our definition...our whole life is an emergency), high or low?

    If it's any comfort to you if it doesn't work out, you may want to hold out for improvements they're making. Like you, I wanted to provide my son every medical advantage we could get. I fought for the CGM...and we rarely use it now. It's useful in some ways (I love that you can see if they're going up or down and how rapidly), but not accurate enough to be really useful in the way we hoped and to justify another attached piece of equipment with a long, threatening insertion needle. Best to you,

    ~Linda
     
  3. cm4kelly

    cm4kelly Approved members

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    I know this is frustrating. . .

    I know this must be frustrating. We have two type 1s. Quite a few year ago my husband attempted to get a CGM and his insurance denied him because they said his blood sugars were too good! CAn you imagine that? So he should attempt terrible control to be approved? THat is absurd. He dropped his attempt with insurance.

    Fast forward to two years ago with my then three year old. We did get our CGM approved - but I am sure every insurance company has different hurdles to jump through. I submitted logs of blood sugars showing lows - especially during the night that had I not gotten up - could have been disastrous.

    I also attached a personal letter showing three specific examples of times that my son had dangerously low blood sugars that could have been prevented by having a CGM. For example, my son was at church in the children's program. When we went to pick him up, his head was down and he was asleep on the table. It was VERY HARD to wake him up. We immediately checked his blood and started sugar treatment. BG = 32. If he had had a CGM this low sugar could have been prevented through prediciting low alarms.

    I used several instances like that with his unawareness, especially at night of low blood sugars and how the CGM could help and PREVENT disastrous things from happening to such a young child.

    I don't know if and when you can reapply, but try it. Also - I know they look for a specific number of low blood sugars, so make sure there are quite a few on your logs you have to turn in.

    Good luck!
     
  4. HanksMom

    HanksMom Approved members

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    Thanks for the feedback!

    I think part of the reason I am so frustrated is that we weren't even given a voice. We didn't submit logs or anything. Our doc wrote the letter of medical necessity; it was denied. We appealed, which took it to the level of the doc and the medical director of the health plan discussing it peer to peer, and another denial.

    Unfortunately (?), his last two a1c's have been 7.5, and no detected lows under 40, but we average 12 tests every 24 hours to get this.

    I work for the healthcare system, which is a large, well-respected academic medical center that our Endo is a part of, and that the self-funded insurance is managed by.
     
  5. William

    William Approved members

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    We got approval at 16 months of age, soon after diagnosis but we did have to submit 30 days of readings. Basically they need to see readings in the 40s, at least one or two, we were told by the medical supplier. She also suggested a personal letter explaining the situation. So we discussed how a toddler cannot communicate lows and are essentially hypoglcemic unaware,etc.

    We use a dexcom and there are times when it is not accurate, mostly the first night/days, but you learn when to expect that or suspect it (the new g4 is supposed to be accurate much more quickly). It has been a wonderful tool in alerting us to lows and unexpected highs too, but also in learning how to better control blood sugar. It will also greatly reduce the finger tests.

    I hope you get approval, it should be automatic for young kids.
     
  6. AirforceType1mommy

    AirforceType1mommy New Member

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    Nov 3, 2012
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    Kim, I am going through the same darn thing! Arielle is 4, she was diagnosed right after her second birthday. Got on the pump two months later. I've been trying for two years and it is so frustrating. I share your frustration on so many levels. We check Arielle's sugars 15 times average a day. She wants to sleep when she is having a low and still has no clue when she is low. She had a 32 once and was normal. We have submitted countless letters, logs and appeals and I'm going to keep fighting it, if not for my daughter for other children. I have heard of many kids under 7 that have it and it has been a godsend (they only deny the cgm because Arielle is not at least 7). I really hope you continue to fight because we are the advocates for our kids. I am hopeful. I'd love to keep in contact with you and maybe we could help each other. Good luck lady :) xoxo Jessica
     

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