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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. kajumom

    kajumom Approved members

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    Weird. I have heard of all the problems so I was expecting it. But when we applied for a CGM from BCBS Oregon for the Dex we were approved immediately and had it in less than 2 weeks. Sent in 2 month of logs and the app and that was it.

    I would think there would be some argument that other kids have been approved through BCBS...
     
  2. KHM

    KHM Approved members

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    The Devil's in the details as always. Our policy says that they provide coverage at 100% when medically necessary but of course they're very coy in saying how that determination is made. MM is having a huuuuge problem now for another family with the same insurance: they gave pre-authorization at 100% but when MM submitted the claim to them for payment it came back as a denial because they disputed the medical necessity (without saying what criteria were not met).

    So---Medtronic told me about this; said they thought our documentation was very solid but that I should be prepared for an appeal. In the meantime, they ambushed me with samples of the supplies so if we can't overturn any denial I won't be out the $$$.

    I'm hoping things go well, but if not... I'm ready to take it on a fight.

    I hope your DH will at least open the subject with his employer. I'm sure they must have Open Enrollment season for benefits each year---leading up to those periods the HR Team should be "shopping" for plans that meet their employees' needs. It always help if they know where there are gaps that matter in their workforce.
     
  3. Lawana

    Lawana Approved members

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    Just wanted to add my count as one who has been denied CGMS coverage from BCBS of IL for the reason given in the OP. I will be waiting to hear how anyone has successfully appealed the denial.
     
  4. Yellow Tulip

    Yellow Tulip Approved members

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    I'll post any updates I have. Hopefully some really good ones! :D
     
  5. Lawana

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    Thanks. :)
     
  6. jules12

    jules12 Approved members

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    Several years ago, we were denied by BCBS because it was "experimental" at that time. We had to fight to a 2nd level appeal - they denied my first appeal and almost had to appear before a panel but the people in the panel agreed with us.

    The endo wrote a letter of medical necessity and then had to write another letter addressing the appeal. I also had my school nurse write a letter to confirm the lows that my child got at school which he didn't feel.

    Good luck - my only advice is just to keep fighting. I think they hope that people will just give up and they won't have to cover it.
     
  7. sage68

    sage68 Approved members

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    We don't have BCBS but our first request for a CGM was denies, as was the 2nd, 3rd and 4th request. Each time I appealed their decision and finally requested and outside review of our request. Our pedi then went in front of the Durable Medical board to explain to them why it is medically necessary for my girls to be on a CGM and it was finally accepted i think start to finish was about 3 months. Just don't give up! That is what the insurance company is hoping for. I scoured the Internet for resources and information in support of CGM's, especially in small children. I printed off all of my research and then wrote letters that referred to each source and sent it all in. The last appeal i sent in was over 20 pages long, and that isn't including all the supporting documents i sent in with it! I also printed off 3 other insurance companies Durable Medical policies that do cover CGM's and sent that in.

    Good luck! Just be persistent and DONT GIVE UP! It is a frustrating and aggravating process but so rewarding when you finally get the acceptance letter.
     
  8. KHM

    KHM Approved members

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    You fought a long and tough battle---don't you feel great that you finally overtook them? Its something to be proud of.

    Do you mind my asking how this played out? Was it the case that you received the equipment and then had to fight for reimbursement?
     
  9. TracieandJim

    TracieandJim Approved members

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    Thank you everyone for the info. Aetna denied us CGM coverage this year in spite of the fact we have a CGM that was approved from UHC. Next year my insurance changes, sigh, again to BCBS. I already looked ahead at their coverages and it says they will cover it. But ... we shall see.
     
  10. rmccully2000

    rmccully2000 Approved members

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    Just denied also with BCBS of Illinois. Mason has been using the Dexcom for 4 years and our company just switched from UHC to BCBS and they gave me the 25 year old excuse also. Time to dust off the appeal letters. We need an Easy Button for this!
     
  11. sammysmom

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    I know that BCBS of Michigan is now covering CGM's...I wonder why it is not standard for all BCBS's?
     
  12. MReinhardt

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    Sorry..count not resist! :D

    [​IMG]
     
  13. hawkeyegirl

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    Not only is it not standard for all BCBS, it is not even consistent within the same state. We have BCBS HMO of Illinois, and we're 100% covered. BCBS PPO of Illinois denies CGM totally. :rolleyes:
     
  14. Yellow Tulip

    Yellow Tulip Approved members

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    Michelle, love the button! But it doesn't work!!!! :eek:

    Karla, you've told me that before and it totally doesn't make any sense at all! I just don't get all this insurance stuff.
     
  15. ACrawford

    ACrawford Approved members

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    Have BCBS of IL PPO and keep getting denied the cgms for my 2 year old. It's not medically necessary. WHAT??? Then you come check him 4xevery night and try to guess when he's low!

    Karla, you have BCBS of IL HMO and you were granted a cgms? Trying to gather data for my defense when I request an external review. I just don't get it. There are several BCBS plans that cover it for kids. Why doesn't IL's?
     
  16. hawkeyegirl

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    Yes. BCBS IL HMO covers them automatically. I can't figure out why the PPO does not :(
     
  17. tiger7lady

    tiger7lady Approved members

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    The reason the BCBS HMO probably covers it is because the medical group you select is the one actually paying the bill - not BCBS of IL. We will be going through the process soon and when I came across that 25 year old rule in BCBS stuff I was very disappointed but my DH (who is a medical insurance broker) pointed out that the HMO gets paid by the medical group and our medical group DOES pay 100% for it.
     
  18. kemjris

    kemjris Approved members

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    I have Capital Blue Cross in Pennsylvania and Morgan was denied CGM because she hasn't been admitted to the hospital enough?????:eek::confused:

    Still fighting. No luck so far. Any suggestions given here will be greatly appreciated.
     
  19. Caydens_Mommy

    Caydens_Mommy Approved members

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    We have BCBS Health Select of Tx, we have gotten coverage both times we have requested the CGM.. I had been told several times there would be a fight but there was none.. This last time (few weeks ago) I did not even have to send in logs..

    I agree that it is strange how some BCBS cover and others don't.. Doesn't make alot of sense.. I hope your fight goes well, plenty here have some great advice!
     
  20. ACrawford

    ACrawford Approved members

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    So basically it comes down to money. Just what I thought. What BCBS doesn't get is the cgms could prevent hospitalization. Preventing ONE hospital visit would pay for the cgms and supplies for several years!!
     

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