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Has anyone with Aetna (NY) been approved?

Discussion in 'Insurance Issues' started by Ellen, Jul 17, 2008.

  1. Ellen

    Ellen Senior Member

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    HELP!

    My friend was just denied a cgms from Aetna today. Aetna continues to claim the MM CGM is experimental and investgational.

    Some of the language in the letter is as follows:

    A charge for a service of supply is not covered to the extent that it is determined by us to be experimental or investigational

    A
    medical policy admin medical director board certified in internal medicine has reviewed your request, including all supporting documentation submitted to date.

    A
    fter this review we have determined that the proposed medtronic minilink transmitter and system are not eligible for payment

    Aetna considers the long term use of cgms medically necessary as an adjunct to finger testing of BG in persons with type 1 who have had recurrent episodes of hypoglycemia

    Long term use of cgms are considered experimental and investigational

    While this response indicates services would not be payable we want to emphasize that the member and physician make the final determination whether the proposed treatment is performed

    Has anyone overcome this?

    Thanks.
     
  2. BrendaK

    BrendaK Neonatal Diabetes Registry

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    That's discouraging!! They are using the language in their new policy that states it IS medically necessary for type 1s with hypoglycemia, but they are STILL denying it. What dirty rats :mad:
     
  3. jane1218

    jane1218 Approved members

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    Aetna changed thier policy on cgms July 1, 2008. My daughter's endo put the request in to Aetna July 8. The doctor wrote a letter of medical necessity. The minimed rep called to let me know that Aetna will take 2 week to make a decision on whether it is necessary in my daughter's case. I posted the link to Aetna's policy on this board a couple of weeks ago, but I am sure it is buried in a thread. I will post as soon as I know the outcome.

    Here is the link:
    http://www.aetna.com/cpb/medical/data/1_99/0070.html

    Jane
     
  4. Marcy

    Marcy Approved members

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    Sounds just like my Appeal denial letter pre-July 1

    How can they STILL say that? When I called MM to get the process started w/ Aetna (AGAIN), they took all my info, asked for at least 2 months worth of bG readings and asked specifically if I had more than 5 episodes below 50 per week. They said they would send it in to Aetna for Predetermination and that it would take "2 weeks." It has only been one week.....I am really hoping this goes through!

    Did your friend submit bG readings with her request?
     
  5. Momto4

    Momto4 Approved members

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    This is the EXACT response I received about 6 months ago from Aetna. My daughter had a severe low (23) this weekend, she passed out, glucagon was given, 911 was called, etc. So, first thing Monday morning I called Minimed and ordered the CGMS. The rep reviewed my old information and told me that Minimed had just signed a contract with AETNA within the last month or two so it should be easier to get it approved (we'll see!). Anyway, he told me that a rep from AETNA should be calling me within 2 business days to get some more info and review the coverage of the system. So, we shall see. I will post any additional information as soon as I hear from AETNA.
     
  6. BrendaK

    BrendaK Neonatal Diabetes Registry

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    I'm just starting the paperwork for the Navigator and we have Aetna. And I noticed that they only specify Minimed and Dexcom :( We're up against a monster I feel like!
     
  7. jane1218

    jane1218 Approved members

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    Just recieved denial letter from Aetna

    It said...

    "A medical policy administration medical director, board certified in Anesthesiology has reviewed your request, including all supporting documentation to date. After this review, we have determined that the proposed Medtronic Minimed Paradigm Real Time CGMS is not eligible for payment. Aetna considers the long term use of cgms devises medically necessary as an adjunct to fingerstick testing of blood glucose in persons with type 1 diabetes who have had recurrent episodes of severe hypoglycemia (LT 50 mg/dl) despite appropriate modifications in insulin regimen and compliance with frequent self monitoring (at least 4 finger pricks per day)"

    1) Why was this reviewed by an Anesthesiologist???
    2) How many episodes does she have to have?
    3) We test between 8 and 15 times a day...

    My downfall is I am a terrible record keeper. So I have data a few weeks at a time. When I review her numbers I write them on a scrap papers and make adjustments, then loose the paper. I try to down load her meter and pump, but then she lost her pump uugghh. so I am missing a few weeks of data. I have hope though, I seem to always be able to pull something together. I am now off to search for all those stupid scraps of paper...

    My goal is to have the cgms before school start in September.

    Jane
     
  8. Marcy

    Marcy Approved members

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    Aetna reversed their denial!!! (TX)

    I just received the letter today. It states:

    Although there is no documentation of attempts to manage this patient's glucose swings with insulin dosage adjustments, based on the nocturnal hypoglycemia, I will authorize the use of the CGM for this patient.

    I can't believe it!! This was my Second Level Appeal. I sent in 3 months worth of bG readings. (Low was 22, high was 574) I had 7 readings of below 50 during the night. With the other letters, I did not include bG numbers, so my guess is that is what swayed them. If anyone would like to see my Excel log (or my appeal letter) I'll be glad to forward it--I copied the log from someone on TuDiabetes.

    WOW--The 7 month long fight was worth it!!!

    Marcy:)
     
  9. otter005

    otter005 Approved members

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    I know this is a older post, but we just got approved by Aetna for Minimed cgms. We wore the gardian for 5 days, and based on those results they have approved us for long-term use. We did not experience the hyPO issues more so the hyPER issues. There is hope!!
     
  10. vettechmomof2

    vettechmomof2 Approved members

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    We are just now starting the figth after they informed Dexcom that it would be covered but sent me a denial form. At least I have experience in doing this.:rolleyes:
     
  11. vettechmomof2

    vettechmomof2 Approved members

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    Update: we were just informed that as of 2010 Aetna changed their policy looking for specific coding. If your chidl does not have a specific code number then they are deined stating that the cgms is experimental for anyone under the age of 25:eek:.
    Will continue the struggle tomorrow.
     
  12. jan123

    jan123 Approved members

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    I got approved for the Dexcom in Jan. All I had to have is a letter of medical necessity. Aetna was a piece of cake !

    Janice
     
  13. swellman

    swellman Approved members

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    Aetna, NC was one week from my emailing the forms to acceptance - Dexcom here we come.
     
  14. vettechmomof2

    vettechmomof2 Approved members

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    Still fighting Aetna here :(:(:(:(
     
  15. manda81

    manda81 Approved members

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    The code for Aetna's approval is 250.83 (Diabetes with unspecified complications).

    We got an approval, but instead of it being filed under our "diabetic supplies" they're filing it under DME, and with the deductible, it's not really saving us anything. =/

    Ugg.
     
  16. fredntan2

    fredntan2 Approved members

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    Back in august when we got our new mm pump and cgms.the cgms wasn't paid for.i went back and forth with all parties involved. Finally gave up..dd only wore the cgms for 2 days.she didn't like the larger needle. It was a coding issue.

    We had a dexcom that she prefers. That sensor piece is now missing.am waiting for the updated mm cgms to debut here in us
     
  17. nanhsot

    nanhsot Approved members

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    Yes, this. We have Aetna and pretty much everything but insulin and strips (so all pump supplies) are DME and only covered 50% AFTER deductible. I've had to work weekends this year to cover it all.

    I'm in the process of applying for CGM now, and it's also covered as DME. I will have met the deductible soon, so only paying half will seem like a break. :rolleyes::rolleyes:
     
  18. manda81

    manda81 Approved members

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    Aetna covers our pump (Omnipod) at 100%, I have no idea how we lucked into that one, but I'm not complaining.

    They are covering our CGM, but with the deductible, it's about the same as people who just pay OOP. :rolleyes:
     

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