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Just got a denial letter from BCBS for CGMS

Discussion in 'Parents of Children with Type 1' started by Yellow Tulip, Oct 8, 2010.

  1. Yellow Tulip

    Yellow Tulip Approved members

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    The denial was based on DS's age: according to them, CGMS is not medically necessary for patients under 25 years old. Really? Did any of you have to appeal an insurance denial? What is the process? Any tips? Thanks a bunch!
     
  2. Flutterby

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    We have BCBS and had no problems. What cgms are you trying to get? I'd appeal.. Start with a letter of medical necessity.. show proof of lows and highs, and hypounawareness.. this is common with insurance.. why under 25 is it not medically necessary? Its approved for 7 and above by the FDA (MM that is)...
     
  3. Yellow Tulip

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    This is a stupid rule that BCBS PPO has here. I don't get it either. We're trying to get the MM CGM to go with his Revel pump. I submitted to them the Ipro results already that clearly showed nighttime lows down to the 40s. Not sure what else to do. I guess I'll contact the endo and make sure they give me or sent them the letter of medical necessity and see what happens. I know I'm not taking this no for an answer, but am not sure what to do next.
     
  4. arogers

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    We were originally denied by BCBS also because we wanted the Dexcom and it is not approved by the FDA for children. MM is the only one that was approved for children at the time, so once our endo had a "peer to peer" review we had no problem getting it. Now, if only I could get my son to wear it!

    Anne
    Mom of
    Brad 14, Scott 12 (dxd 3/07, Omnipod since 10/07) and Jay 8
     
  5. KHM

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    You need to write a letter of appeal---that process should be described in your denial. That's what it takes, Arleta: shove the data in their faces, cite the literature that supports reduction of hypos, etc. I'm sure I'll have to do it, too. Describe in detail what the circumstances were around a recent hypo, how it played out and how it affected Tommy and everyone in your family. Describe your present routine for monitoring blood glucose which I'm sure includes middle of the night checks.

    A denial of CGM coverage is practically a guarantee of episodes of hypoglycemia, hyperglycemia and DKA. The MM CGM piece is a maximum of $1000 depending on their contract plus the monthly DME---still a single episode of DKA and hospitalization is thousands of dollars up front and puts Tommy at increased risk for complications as his life goes on.

    Go get 'em!
     
  6. colebenmom

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    We have BCBS PPO too and somewhere in the process we were told that rule. However, the MM rep took care of everything and sent in some logs and we were approved. Good luck.
     
  7. dianas

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    The 25 year age limit reminded me of a CGMS study that showed CGMS was beneficial in adults but not always with children. Of course this was just one study and there are others that show the opposite. Also if I remember correctly it all depended on how much it was used or something like that. I don't really have time to find the original study but I think this article refers to it and perhaps this will lead you to the real thing rather than just this article... Or perhaps others will have a better link.

    http://www.diabetesselfmanagement.com/Blog/Tara-Dairman/study_shows_real_benefit_from_cgms/

    My guess is your insurance policy is using this study to draft their policy for CGMS coverage. For your appeal you may want to find all the studies that refute these findings in children.

    Sorry this is happening.
     
  8. miss_behave

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    How'd they figure that one out?:confused: Does diabetes somehow magically change on one's 25th birthday? :rolleyes:
     
  9. Yellow Tulip

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    Thanks guys. I'll start putting together a package of studies to prove our point. Hopefully the MM rep we're working with can help getting this denial reversed. We'll see. Thanks again!
     
  10. KHM

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    If you'd like help, I have good access to medical literature. This seems like an issue that will be raised many times at CWD and maybe we should try to compile a forum resource (if there isn't already something along those lines; I mostly only visit the boards).
     
  11. MReinhardt

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    When Chell first inquired about her CGMS, she was denied from medicaid. Between MM & Peds Endo, they did all the work. It was approved, she's been using it now..for almost 3 years, with medicaid from two different states approving it. What was used:

    Bode B, Gross K, Rikalo N, Schwartz S, Wahl T, Page C, Gross T, Mastrototaro J. Alarms Based on Real-Time Sensor Glucose Values Alert Patients to Hypo-and Hyperglycemia: The Guardian Continuous Monitoring SystemT. Diabetes Tech & Therapeutics 6:105-113, 2004.

    MM should be helping you also in the process. You also might want them to show the "Guardian", its FDA approved for peds usage.
     
  12. Mike&Dans.Mom

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    BCBS of Illinois automatically denies the CGMS. Your endo is going to have to write a letter of necessity and go from there.

    I have a friend that fought BCBS IL. for months on this. I will ask her how she got them to approve the dex for her son.
     
  13. KHM

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    Nice, Michele; thanks from all of us who may need this info!
     
  14. KHM

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    Arleta, one further consideration as you move forward. Insurance companies have very little to lose in the short term by denying the request. You'll be annoyed, Medtronic won't like dealing with them but they don't feel much of that fall out until people start making noise.

    So that's where your appeal begins. You're a subscriber to an employer-sponsored plan; you might have other insurance options available to you and maybe they should be reminded of such. Further, if you find yourself with a supportive Human Resources Benefits team, it would be really compelling if they might submit a letter that you could prepare that would indicate their surprise (and dissatisfaction, I would imagine) at the disregard for Tommy's wellbeing. Employers who purchase these plans can have a
    really big impact on insurance business successes and failures.

    Crossing fingers and watching how things go...
     
  15. timkris724

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    A couple of years ago I had to write a letter of appeal for my other child to get a helmet to fix a mis-shapen head. I cited as much research from medical journals as I could and included pictures. I bet Jeff has some very good article he could share. We should have a folder on this site with research that would be useful in appealing for pumps, cgms, ect..

    Please be sure to post whatever type of appeal you make. I myself may need it in the future, so far we have been ok, but I was expecting a fight at 6 months.
     
  16. TheFormerLantusFiend

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    I also got denied by BCBS IL PPO on those same grounds.
     
  17. Yellow Tulip

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    Thank you Michelle! I just looked over the link you posted and it definitely looks very helpful. I didn't realize that MM can play a big part in the appeals process. I just sent an email to our rep telling him that we'd like to appeal the decision and asking what he would need from me and the doctor. Thank you for pointing me in the right direction.
     
  18. Yellow Tulip

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    Thanks Jeannine! I would definitely be helpful to know how someone else managed to get what they needed. Thanks again for looking into this for me, and really, all of us who will need to fight this battle at some point.
     
  19. Yellow Tulip

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    Kristin, I don't know, maybe there is a section on the CWD website somewhere dealing with insurance trouble. I'll have to take a closer look. If there isn't, starting one could be a really good idea. Although I'm not sure how standardized it could be, given so many different insurance providers.

    Regardless, I'll definitely keep you all posted on the progress of the appeal. Hopefully I'll have some good news soon :cwds:
     
  20. Yellow Tulip

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    Kathy, thanks so much for all your ideas! I talked to DH (the insurance policy is through his employer) about contacting their HR department, but he doesn't have much faith in them doing anything about it :(

    My first line of action is to contact MM and see how much they can help. If I need to start digging up medical lit, I'll definitely PM you :) Thanks for your offer to help.

    You mentioned you may need to fight this too soon - I thought you were 100% covered :confused:
     

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