Our Medical Director has determined that the request is: Denied – Not Medical Necessary.
After consideration of all available information, our Medical Director has determined that the requested procedure will not be covered for the following reason(s): Based on health plan criteria for diabetes care, your request for continuous blood sugar monitor and supplies is denied. This is because we did not receive the needed information from your doctor. You have diabetes and take insulin. We need to review your medical records showing your present diabetic condition and medical history. We do not know if your blood sugar cannot be controlled despite multiple insulin injections during the day. We do not know if you use up to three insulin injections per day. We do not know if you check your blood sugar level at least four times per day. We do not know your blood sugar levels. We do not know results of your blood sugar test called hemoglobin A1C. The medical equipment company supplying these items and your doctor were asked to send in this information to us.
We have provided a detailed explanation of the Member’s appeal rights below. A Member has the right…..
YEAH, this actually happened along with 9 more pages of incredibly specific instructions of how to appeal this decision. There is a one time appeal. Yes ONE. There is a possible option/request by your doctor for a peer-to-peer review (doctor from insurance company and your endocrinologist chat but it isn’t scheduled for a specific time. HUH? Needless to say it sounds like an option based on luck just to get the call) and there is a petition for an external review appeal. Does this all sound daunting? Yes it is. I received the letter above the night after my first JDRF cycling training ride which I believed would be 9 miles. Nope. 27.5 miles. It also snowed! But back to DENIAL.
I have been using Dexcom CGMs for what I believe to be 4 years now. CGMs have improved my quality of life tremendously and allowed for some incredible fine tuning of BGs, exercise adjustments, and timing of insulin dosages. As someone who has had hypoglycemic unawareness (first training ride, even with all my aggressive basal reductions I was treating lows (some in the 50s) the entire time. I didn’t feel them. I was shivering and cold and cycling and huffing and puffing and hoping to not get hit by cars or crashing), and a CGM has been a welcome addition to my T1D upkeep. Changing health insurance has been a bit roller coaster-y, BUT when I received a call that my Dex was out of warranty, then having the whole system replaced in January (under new insurance) and then upgrading to the Dex Share bluetooth receiver, I thought any fear I had about approval was for naught. Yep and then I got a crushing Denial letter.
Based on the information above, one might assume my doctor never sent in the proper medical paperwork… I thought that too. Me = LIVID. Nope. One might also think the insurance company lost it or was just being a bunch of bullies. Nope. One MIGHT think the Dexcom 3rd party supplier completely F-ed up the paperwork and then lied and lied about it and then people kept getting reassigned my case (huh?) and someone, by the grace of God, may have “slipped” that they (3rd party) never submitted my doctor’s paperwork even though I had visual proof they had indeed received all my medical notes on time. Yes, then you “may” be right. What a mess and what an exorbitant use of my time.
At my absolute wit’s end (which says a lot because I’m pretty damn witty sometimes), I just put my head in my hands and wondered how the hell I was going to fix this, and that I just wanted a break from this Monday through Friday daily morning fight (did I mention this has been going on for weeks now?). My sketchbook slipped off the mound of paperwork on my desk and I saw something I wrote on the 2nd to last page.
“Fight For What You Love”.
I don’t know when or why I wrote that in a work sketchbook (weirdo) but there it was and my Dexcom was buzzing in my lap and I remembered something. Something else I wrote. Something I loved writing. Something that made me smirk. I wrote this in 2012 about LOVE. Please read that link for this to all (well sort of) make sense. I’ll wait.
And that was it. Fight For What You LOVE. So I continue to fight. I’ve consulted with an attorney, I reached out to my T1D network, my insurance network, my CGM network, my insurance company, I called every party involved in this fiasco. I wasn’t DENIED because it wasn’t considered medically necessary. My denial (at this point) is a paperwork snafu. ONE appeal. And I FIGHT because I have to and I fight BECAUSE. I. LOVE.
As this continues to ebb and flow and there has been more hope in the last 2 weeks (but I never truly lost hope), I have thought about something everyday. What do other people do? What do people do who have a job where they don’t have phone access? A job where they can’t make calls during all these company’s involved business hours? What do people do who don’t have a network to reach out to. I’m not the first person to fight a denial letter. What about people who are denied an insulin pump? Or are told they are not covered for the amount of BG test strips they use daily? What do they all do? How many people hit the give-up point? What do they do? I remember many years ago being approved for only 6 BG test strips a day even though my prescription was for 8 per day.
I’m curious about other people’s denial stories and what resources you/they used.
More about my saga later. Boxing gloves back on.
I was denied a little over a year and a half ago. My insurance company said that my A1C was below 7, I am not pregnant and do not have any extreme low bgs. I have not had time to fight for my CGM, but I’m going to make time within the next two weeks.
I thought this was resolved a while back and so sorry to hear that you are still battling. But keep up the good fight and you will prevail. And send them the blogpost you wrote when on a business trip without a sensor. Oh I know stuff like that doesn’t matter (to insurance companies) and hope everyone gets their ducks in a row with the necessary paperwork.
Hey A, Get on the phone… Go up the ladder… Listen for phrases like not cost-effective… Not cost-effective to whom? Some pencil pusher?, the insurance company?… If you are persistent… You’ll get it approved… I have, every time.
Meanwhile, I had to fight to cancel prescriptions placed for me for things I don’t need and don’t use (twice in two weeks). I know it’s stupid, but if you get them to give up enough of their time fighting over this, they will give in. That’s why they only want to give one appeal. More appeals would mean more time investing in denying you what you need and deserve, and they don’t want that.
Fight for what you LOVE. You’re worth it.
This sucks. I’ve had to fight for CGM coverage and it’s unpleasant and demeaning. But lucky for you (this time anyway), it seems the whole problem is due to a paperwork snafu.
My suggestion is that you don’t escalate this to the level of an appeal. Simply have your provider submit a new claim — with a new case number and everything, and with the proper paperwork. Start from scratch with them. Viewed independently, that should result in a favorable decision for you. And if not, THEN you have an appeal available to use, and you have the documentation on record to prove that THEY messed up and not you.
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