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Fighting the CGMS Denial

Discussion in 'Parents of Children with Type 1' started by Shirley and Jamie V., Feb 13, 2009.

  1. Shirley and Jamie V.

    Shirley and Jamie V. Approved members

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    I am hoping someone at CWD can help me locate the web site or other documentation that refutes the designation of the Constant Glucose Monitoring Systems as "investigational." Our insurance carrier Community Blue, a part of BlueCross and BlueShield of Western New York, has denied our request for a monitoring system for our daughter Maggie on the grounds of several indicators, including "lack of clinical data to support any improvements in outcomes." Clearly better diabetes management, sleeping through the night and peace mind do not count.

    Let me know what has worked for you in the past as I know some of you have fought this battle before and were successful.

    Thank you!
    Shirley Verrico
     
  2. Abby-Dabby-Doo

    Abby-Dabby-Doo Approved members

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    This is a common mistake made when fighting your insurance company for using the words "investigational"- Please look at your insurance booklet and find out what they consider "investigational" means. It is located somewhere in your booklet and it will list HOW you fight this or another words what they want.
    I wish I was home so I could type mine out for you, so you could better understand what I'm saying. I'll check back on this thread and see if you could find what I'm referring to.
     
  3. Shirley and Jamie V.

    Shirley and Jamie V. Approved members

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    ADA just sent me the following:
    Here is a link to a study published in the New England Journal of Medicine that shows that CGM has clinical data that improves outcomes. In addition, Maggie's doctor can resubmit with a letter of medical necessity. This is where it should say why she needs it - here are some of the "buzz phrases" that have been able to get the device approved for other patients:

    http://www.eurekalert.org/pub_releases/2008-09/jdrf-jfc090808.php

    Here is also a link to a blogger who is also trying to get the CGM covered - she uses some good arguments in here... some additional ideas.

    http://sixuntilme.com/blog2/2008/09/cgm_study_shows_this_stuff_wor.html

    1. hypogycemic unawareness "Maggie doesn't always feel her lows and this device will help avoid potential deadly consequences" **This one seems to work the best especially for a child**

    "We are applying for the CGM because Maggie's body does not recognize the symptoms of low blood sugar with any reliability"

    2. A1c out of range - if it is out of the recommended range (even if it is 7.5 ADA's range is 7.0 and uder) - you can say that the CGM will help get better control and avoid the potential outcomes and side effects

    3. Large fluctuations during day - "dawn phenomenon"

    Anything that is out of the norm - (even if you are taking good care of yourself) - that will help get this approved.

    My husband is a lawyer and is looking into this.

    Thanks on letting me know where to look. Our daughter just had a huge growth spurt and puberty is just around the corner. We need some help with the control, and a full nights sleep would be great too!

    Thanks,
    Shirley
     
    Last edited: Feb 13, 2009
  4. Abby-Dabby-Doo

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    I don't have to wait till I get home I found it on one of my CGMS fighting appeal threads...
    This is straight out of our insurance booklet on what they state is INVESTIGATIONAL
    This is my OLD post


    Any ideas, words I should use, approach I should take, to these reasons why my insurance company is stating the CGMS is experimental/investigational...

    Any treatment, procedure, facility, equipment, drug or drug usage, device or supply that is not accepted as standard medical practice by the general medical community or us, or does not have Federal government agency approval for its use or application.

    The Plan's experimental/investigational determination process is based on authoritative information obtained from medical literature, medical consensus bodies, health care standards, database searches, evidence from national medical organizations, State and Federal government agencies and research organizations. The review and approval process for medical policies and clinical practice guidelines includes clinical input from doctors with specialty expertise in the subject.

    Another words this is how I had to fight my appeal- According to the first paragraph they were stating it wasn't FDA approved OR it's not accepted as standard medical practice by the general medical community. I sent them the FDA's approval on the device we were getting, and I fought the standard practice statement with giving them the insurance codes. If there is insurance codes out that companies are using that is pretty standard to me!
    In the 2nd paragraph I sent them medical literature, JDRF research, found Dr's from the "big" hospitals that supported the technology and wrote stuff about it, took quotes out of books, and so on and so forth.
    I fought the insurance companies reasoning from the insurance booklet itself on what they were saying they needed so the CGMS wasn't investigational.
     
  5. Shirley and Jamie V.

    Shirley and Jamie V. Approved members

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    THANK YOU!

    It is great to learn from those who have been successful. I can't tell you haw many people say "wouldn't it be great if there was a devise that could monitor her sugar levels all the time....." and then I say there is, but the insurance won't cover it.

    It's crazy. Cross your fingers for me and my Maggie.

    SHirley
     
  6. Abby-Dabby-Doo

    Abby-Dabby-Doo Approved members

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  7. Abby-Dabby-Doo

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  8. Darryl

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    When we were going through our fight with IBC, we showed a letter given to us by
    another CWD parent from the FDA that clearly stated "The CGM has received full and
    final approval and is no longer considered investigational by our agency". The insurance
    company replied "We are not bound by the FDA's opinion", and that was that.

    Ultimately, we lost all appeals, but IBC then changed their policy to cover CGM's.

    Generally I think you need to approach appeals as follows:

    - Know in advance that they've "heard it all before" and nothing you present will be new
    information to them.

    - Concentrate on getting an exception based on severe hypoglycemia, near-DKA, and
    other complicating health factors that make your child worthy of an exception. I am sure
    that these factors apply to you, even though I don't know you!

    - Concentrate on educating the review board. We used many of the articles on the website
    above. Educate them, and ask them to formally submit your prsentation to the insurance
    company's policy committee if they are unable to approve your appeal. We were told by
    our appeal reviewer that he did present our information to the IBC policy committee,
    which could possibly have contributed to the change in policy that was adopted shortly
    after our appeal denial.

    - Use peer pressure - show the review board policies from the other Blue Cross franchises
    that do cover CGM's, and mention all of the other companies on the website Lanae listed
    above, to show them that they are behind the curve in not approving CGM's. Specifically,
    show them Independence Blue Cross' new policy 5.00.24e:
    http://forums.childrenwithdiabetes.com/showpost.php?p=288263&postcount=1

    Good luck and I hope you get coverage!
     
  9. sneakermom

    sneakermom Approved members

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    Don't Give Up

    We had to go through the denial process as well. It is slowly but surely being accepted by more and more insurance companies though. Keep fighting the fight. They count on people giving up. What helped us were letters of medical necessity from our doctors listing many of the same things that were previously stated. There was also a study that was released back in (November?) that showed the CGM's benefits in the pediatric population. It was shortly after that study came out that we received the go-ahead on it. The device was well worth the hassle.
     

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