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CGM Insurance Coverage

Discussion in 'Parents of Children with Type 1' started by Megnyc, Feb 3, 2013.

  1. Megnyc

    Megnyc Approved members

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    Hi, I am posting this here because I think the most people read here and hoping someone has experience with this. If it isn't an appropriate place I will move it.

    I have switched health insurance companies and I am trying to get CGM coverage again.
    I have several questions after getting 2 denials.

    Are there any studies on the effects of high vs. low standard deviation of blood glucose in type 1 diabetes?
    Is there any evidence that lowering an A1C from perhaps 8.4 to 7.6 has any significant clinical benefits that would translate into cost savings for the insurance company?
    Has anyone gotten UHC Oxford in NY to pay for a CGM in similar circumstances?

    I think we get one more appeal to the insurance company and then we have to go appeal externally which I would hope to avoid. I have time though. I have 2 boxes of Dexcom sensors and 2 boxes of Medtronic sensors remaining. Basically, I have 6-8 months to get coverage :eek:

    Thanks so much!!!
     
    Last edited: Feb 3, 2013
  2. Sarah Maddie's Mom

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    Where is your endo in all this? when we have had to appeal denial of service our Dr has always known how to make the case...eventually.
     
  3. Megnyc

    Megnyc Approved members

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    I believe my parents sent a letter from the endo with our first appeal. Additionally, we included several studies the CDE dug up as well as a letter discussing my unique circumstances (student, full time job) and the amount of work it has taken to get things to be this stable so far. We are also dealing with the fact that the insurance company will not talk to my parents since I am over 18 now, and I am in a different state then the endo and my parents. I have full confidence they will get it sorted out I am just hoping it gets done with the least amount of aggravation possible for everyone. I am also now with an adult endo and there is much less hand holding and experience with insurance companies. I may be one of 2 or 3 patients in the office on a CGM
     
  4. Sarah Maddie's Mom

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    Ok, I can see that it's complicated when you are out of state and over 18... Fwiw, I'm not sure that a cost analysis of the daily expenditures will have much impact. But really, it often just comes down to be a persistent pita to get what you need. :rolleyes: Good luck!
     
  5. redheadmom

    redheadmom Approved members

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    Are you insured in the state of NY? If so, I can tell you what happened to me. I was denied three times by my insurance company. The reasons were "not medically necessary" and "no peer reviewed literature supporting the benefit of cgm".

    I then appealed to the state of NY. I wrote a letter myself (which my endo signed), and attached citations to eleven different peer reviewed articles. I believe all of them came from the Dexcom website. I was approved for a cgm within 2 weeks start to finish of the final appeal. I have been covered ever since (this was three years ago.)

    If you are in NY, it's worth a try to appeal to the state. It was a true God send for me. I really felt like they were "on my side" in the situation.

    If you cannot get ahold of the dexcom citations (not sure if they are still on their website), then give the company a call, or PM me and I will email you a copy of the citations that I used. (I would think it would be worth it to try to get an updated list from dexcom if they have one though.)

    Hope that helps!
     
  6. BittysMom

    BittysMom Approved members

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    We're in NY and have Oxford Liberty. Our CDE submitted downloads from her pump and she checked off hypo unaware, nighttime hypos etc.. I can't find the criteria online like I did before, I'll look again.
     

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