{"id":1314,"date":"2015-04-21T22:26:42","date_gmt":"2015-04-22T02:26:42","guid":{"rendered":"http:\/\/www.surfacefine.com\/?p=1314"},"modified":"2015-04-21T22:58:07","modified_gmt":"2015-04-22T02:58:07","slug":"denial","status":"publish","type":"post","link":"http:\/\/www.surfacefine.com\/?p=1314","title":{"rendered":"Denial"},"content":{"rendered":"

Our Medical Director has determined that the request is: Denied – Not Medical Necessary.<\/em><\/strong><\/p>\n

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.<\/strong> \u00a0This is because we did not receive the needed information from your doctor. \u00a0You have diabetes and take insulin. \u00a0We need to review your medical records showing your present diabetic condition and medical history. \u00a0We do not know if your blood sugar cannot be controlled despite multiple insulin injections during the day. \u00a0We do not know if you use up to three insulin injections per day. \u00a0We do not know if you check your blood sugar level at least four times per day. \u00a0We do not know your blood sugar levels. \u00a0We do not know results of your blood sugar test called hemoglobin A1C. \u00a0The medical equipment company supplying these items and your doctor were asked to send in this information to us.<\/em><\/p>\n

We have provided a detailed explanation of the Member’s appeal rights below. \u00a0A Member has the right…..<\/em><\/p>\n

YEAH, this actually happened along with\u00a09 more pages of incredibly specific instructions of how to appeal this decision. \u00a0There is a one time appeal. \u00a0Yes ONE. \u00a0There 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. \u00a0HUH? 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. \u00a0Does this all sound daunting? \u00a0Yes it is. \u00a0I received the letter above the night after my first JDRF cycling training ride which I believed would be 9 miles. \u00a0Nope. \u00a027.5 miles. \u00a0It also snowed! \u00a0But back to DENIAL. \u00a0<\/span><\/p>\n

I have been\u00a0using\u00a0Dexcom CGMs for what I believe to be 4 years now. \u00a0CGMs have improved my quality of life tremendously and allowed for some incredible fine tuning of BGs, exercise adjustments, and timing of insulin dosages. \u00a0As 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. \u00a0I didn’t feel them. \u00a0I 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. \u00a0Changing 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\u00a0system\u00a0replaced 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. \u00a0Yep and then I got a crushing Denial letter.<\/p>\n

Based on the information above, one might assume my doctor never sent in the proper medical paperwork… I thought that too. \u00a0Me = LIVID. \u00a0Nope. \u00a0One might also think the insurance company lost it or was just being a bunch of bullies. \u00a0Nope. \u00a0One 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. \u00a0Yes, then you “may” be right. \u00a0What a mess and what an exorbitant use of my time.<\/p>\n

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\u00a0I just wanted a break from this Monday through Friday daily morning fight (did I mention this has been going on for weeks now?). \u00a0My sketchbook slipped off the mound of paperwork on my desk and I saw something I wrote on the 2nd to last page.<\/p>\n

“Fight For What You Love”<\/strong>.<\/p>\n

I don’t know when or why I wrote that in a work sketchbook \u00a0(weirdo) but there it was and my Dexcom was buzzing in my lap and I remembered something. \u00a0Something else I wrote. \u00a0Something I loved writing. \u00a0Something that made me smirk. \u00a0I wrote this in 2012 about LOVE<\/a>. \u00a0Please read that link for this to all (well sort of) make sense. \u00a0I’ll wait.<\/p>\n

And that was it. \u00a0Fight For What You LOVE<\/strong>. \u00a0So I continue to fight. \u00a0I’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. \u00a0I wasn’t DENIED because it wasn’t considered medically necessary. \u00a0My denial (at this point) is a paperwork snafu. \u00a0ONE appeal. \u00a0And I FIGHT because I have to and I fight BECAUSE. I. LOVE.<\/p>\n

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. \u00a0What do other people do? \u00a0What do people do who have a job where they don’t have phone access? \u00a0A job where they can’t make calls during all these company’s\u00a0involved business hours? \u00a0What do people do who don’t have a network to reach out to. \u00a0I’m not the first person to fight a denial letter. \u00a0What about people who are denied an insulin pump? \u00a0Or are told they are not covered for the amount of BG test strips they use daily? \u00a0What do they all do? \u00a0How many people hit the give-up point? \u00a0What do they do? \u00a0I remember many years ago being approved for only 6 BG test strips a day even though my prescription was for 8 per day.<\/p>\n

I’m curious about other people’s denial stories and what resources you\/they used.<\/p>\n

More about\u00a0my saga later. \u00a0Boxing gloves back on.<\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

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 … Continue reading →<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":true,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"font":"","enabled":false},"version":2},"jetpack_post_was_ever_published":false},"categories":[1,48],"tags":[187,12,513,510,512,509,511,5],"class_list":["post-1314","post","type-post","status-publish","format-standard","hentry","category-uncategorized","category-diabetes-notes","tag-accidents","tag-cgm","tag-dexcom-love","tag-diabetes-denial","tag-fight","tag-health-insurance-denial","tag-insurance-coverage","tag-t1d"],"jetpack_publicize_connections":[],"jetpack_shortlink":"https:\/\/wp.me\/s2tD0n-denial","jetpack_sharing_enabled":true,"jetpack_likes_enabled":true,"jetpack_featured_media_url":"","_links":{"self":[{"href":"http:\/\/www.surfacefine.com\/index.php?rest_route=\/wp\/v2\/posts\/1314","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/www.surfacefine.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/www.surfacefine.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/www.surfacefine.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/www.surfacefine.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1314"}],"version-history":[{"count":4,"href":"http:\/\/www.surfacefine.com\/index.php?rest_route=\/wp\/v2\/posts\/1314\/revisions"}],"predecessor-version":[{"id":1319,"href":"http:\/\/www.surfacefine.com\/index.php?rest_route=\/wp\/v2\/posts\/1314\/revisions\/1319"}],"wp:attachment":[{"href":"http:\/\/www.surfacefine.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1314"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/www.surfacefine.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=1314"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/www.surfacefine.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=1314"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}