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Dexcom G4 - Insurance Denying Coverage - Toronto, Canada

Discussion in 'Parents of Children with Type 1' started by mo779, Jun 23, 2014.

  1. mo779

    mo779 Approved members

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    Hi all, Looking for some help here. I'm located in Toronto, Canada. I have health insurance through work (Group Plan). I recently submitted a quote through Animas for a Dexcom G4 for my daughter, and the Insurance company denied it, stating that "Your Plan does not cover CGM Monitor & Supplies". I would like to hear from parents that have gone through this. What are my next steps? Is there anything I can do? Is there any chance to get them to change their decision? Thanks.
     
  2. owensmom

    owensmom Approved members

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    You can appeal their decision. Call and ask what the procedure is - for our plan they only meet a couple times a year to review appeals. Provide supporting documentation as to why it is necessary. We were successful in having the CGMS and sensors covered. :)
     
  3. jacks101

    jacks101 Approved members

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    We have appealed to Manulife (covered via my husband's employer - a large national Canadian company) and are waiting to hear. We had to submit all BG readings for a 3 month period as well as evidence that we try to improve insulin doses on a continuous basis. Also, a letter from our doctor about why he felt it was necessary and a letter from our CDE stating our daughter's last 3 A1Cs and that we are "compliant" patients. I submitted everything last month and we're still waiting to hear.
     
  4. mo779

    mo779 Approved members

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    I sent in my appeal papers yesterday. I had already a sent a letter from the Endo, with the initial submission, but they denied that. Now I sent a letter, and a "Certificate of Medical Necessity" from the Endo, and it states the last 3 A1Cs etc.
    My concern is that the initial denial by my insurance company (great west life) was that "Your plan does not cover...." . So now I'm thinking no matter how many forms/certificates/letters I submit, they can just come back and say "Your plan does not cover CGM & Supplies". Is there a condition or a rule that applies, that allows my daughter to be covered for a CGM even though the plan does not have it in the listed coverages. I'm not sure how many plans sepcifically state "Continuous Glucose Monitor" in their list of medical supplies?
     
  5. JackyH

    JackyH Approved members

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    I would love to hear how your appeal works out. We are with Great West Life and were also denied saying our plan doesn't cover CGM supplies. I have not appealed yet. I wouldn't mind so much but we are saving them a fortune in test strips!! More than the cost of the sensors.
     
  6. owensmom

    owensmom Approved members

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    We didn't appeal to Great West we appealed to the administrator of our benefit plan (a board that only meets occasionally to review appeals). For us that was Mercon. You may have to go through your employer to see whether they would be able to override or have CGMS included.
     
  7. mo779

    mo779 Approved members

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    That's a good idea, I didn't think of that. I will get the relevant person at my work involved too, maybe the company can make an exception and adjust my plan to include it. I will keep you guys posted as to how it all works out.
     
  8. KHS22

    KHS22 Approved members

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    We had a letter from our doctor accompany the request, saying all the reasons why she needed it!
     
  9. mo779

    mo779 Approved members

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    Just an update. The fight continues. I have the Benefit Plan Administrator at my work involved, and she is now dealing directly with the insurance company. I submitted all my papers & quote to the Administrator, and I'm told by a number of people at work that she is pretty good in this sort of situations. So lets see, the status of my claim online is back in "Being Reviewed" state, I'm just praying that it turns into "Approved" state soon. Will let you guys know the final verdict as soon as I hear it.
     
  10. mo779

    mo779 Approved members

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    Hi guys, I wanted to post the good news that we were able to get our insurance company Great West Life to partially cover the cost of the CGM and Supplies. My work plan administrators did an amazing job, and were able to get the plan amended to include $3500 annually to use for CGM and Supplies. I know it might not cover the full cost if we use the CGM 365 days a year, but it's a HUGE boost. Maybe we can cycle off a couple of weeks here and there, to bring the total cost down, and spend as little as possible out of pocket. Anyways, just wanted to post this update, and let you guys know to not give up and keep fighting to get coverage. We will probably get the final go ahead by GWL next week, and will order the Dexcom as soon as we do. We are excited, and can't wait. Happy Friday everyone!
     
  11. janinealix

    janinealix New Member

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    You're motivating me to appeal yet again. I am not covered, despite letters from Endo and from my local Senator. Medicare flat out denied me.
     
  12. Nancy in VA

    Nancy in VA Approved members

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    It is true that Medicare will not cover it. JDRF works to get a bill introduced in Congress last week to get Medicare to cover CGMS. There is information on the advocacy web page of JDRF. I recommend you check it out and participate in all the initiatives to help move along Medicare coverage of CGMS.
     
  13. jacks101

    jacks101 Approved members

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    I'm back to report that Manulife finally paid out our Dexcom claim at 90%! I'm thrilled and so relieved!
     
  14. owensmom

    owensmom Approved members

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    So glad to hear that you are getting some of the costs covered.
     

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