I tried again today to get through to someone at our insurance company to try to get coverage details for a CGM and figure out why I keep getting denied. I was once again denied coverage, quoted the specifics of our plan, and I just looked at it again, as something didn’t sound right. I’ve looked at this several times over the past few months, and I finally noticed it (bold type is my emphasis):
“The continuous glucose monitor is covered through Caremark. Therefore, if a member is inquiring about a continuous glucose monitor as a piece of equipment that dispenses glucose that is covered through Caremark. The observing/monitoring of how the continuous glucose monitor is working on a member is covered by UHC based on the place of service.”
No wonder no one can figure it out! Dispenses glucose?! A CGM is not a pump, for one thing, and pumps dispense INSULIN.
It would’ve been laughable had I not been so frustrated. I mean…can you imagine…continuous glucose pump for a diabetic…
Side note: my husband actually said there IS a new device he heard about through work, released just last year(?), that does dispense glucose. Going to see if I can find out what he’s talking about…
You can’t inject it unless it is done intravenously. If you inject it either subcutaneously or intramuscularly it doesn’t work and can damage the tissue.
It may be right about the Caremark part. A while back, I was on a PPO plan instead of CDHP. The PPO covered dexcom as pharmacy, and I had a great low copay.
There have been others who have mentioned plans with similar dexcom coverage as pharmacy. Do you have online access to pharmacy formulary ? Caremark mail order could only supply my sensors, so I used Foundation Care mail order and they were great for transmitter, receiver and sensors.
@MM2
That would be quite interesting to see the details of your plan which had Dexcom as Pharmacy. In the last Dexcom Earnings call, there was quite a bit of discussion on this. Dexcom would very much like to have their product moved into the Pharmacy benefit category however they had admitted this is an area where they have been struggling at best and making virtually no progress at worst.
@Pianoplayer7008
Is the full document online which you could provide a link to? It would be interesting to read it more fully. Clearly something is very wrong there.
In terms of a device which dispenses glucagon, the closest which I have heard is the dual-chambered Beta Bionics iLet Bionic Pancreas pump. This is not on the market. The current estimate by the company is FDA approval of the insulin only device by the end of 2019. The company also plans for the device to first come on the market as an insulin only device and add the glucagon 12~24 months later depending on FDA approval.
For an actual glucose delivering device, this is the best match I could find:
I believe he is probably referring to what @Thomas mentioned - the bionic pancreas.
I’ll have to check and see!
I called UHC again this morning, they referred me again to Caremark. I spoke with a resolution specialist there (again)…who finally told me I need to get my doc to send a letter of medical necessity. Sheesh. Pretty sure she’s probably tried that (I’ve lost track of what we’ve done between this and the Afrezza fight), but we’ll try it (possibly again).
The two key steps are 1. find the actual medical criteria that the insurance company uses to determine coverage, and 2. appeal an adverse decision in a way that is treated as business/legal rather than as a patient complaint.
For finding the medical criteria, search for
[payers name] [treatment category] “medical policy”
For example
UnitedHealthcare “continuous glucose monitor” “medical policy”
Once you have determined that their policy document says you should be covered and you know what you need to document to show you meet their guidelines, the article linked at the top gives strategies to get past the customer service people whose principal job is to discourage you from bothering the insurance company with your troubles.
Aye, there’s the rub. The Certificate of Medical Necessity (CMN) should be the golden key. It is basically the same as a prescription, and Dexcom parts cannot be delivered without a prescription. I have been trying for the past two weeks to get my doctor’s office to fill out and send the damned thing back to my DME so I can get my Dexcom stuff.
Have you just called dexcom and told them you want one? They’re the ones who should be dealing with your insurance, the consumer has zero chance of figuring this out themselves. Consumers directly contacting insurance generally yields nothing but frustration unfortunately.
Yup. I called them, and they referred me to a 3rd party supplier (that accepts Caremark coverage), and I was denied again. I submitted an online form to Dexcom last night; waiting to see if anything different happens.
Thanks, @bkh! I’ve wondered if my diagnosis (LADA) might be the hangup, but from that 2nd link, it does look like they recognize its a subtype of t1, which they do cover as medically necessary. Hmmm.
You’ve filled out the forms for dexcom and such though right? Release of information, who your doctor is etc etc… they will try to fill the prescription and line you out with the third party supplier if your plan requires that— but they’re the ones who will gather the information from your doctor etc to get it approved— you shouldn’t have to be doing this yourself
It sounds to me like you’re just getting a typical insurance run around because the right channels aren’t being gone through… dexcom knows where those channels are, individual consumers don’t…
The only time I contacted my insurance (or their approved supplier) in the entire process was after dexcom had already gotten it completely approved they gave me a 1800 number to call carecentrix to find out what my copay amount would be
I’ve done most of that, yes (again, it’s hard to keep track of what I’ve done for which issue I’m dealing with right now - starting to think I need to write everything down…). It kind of felt like they were just handing me off to someone else, even though I explained the difficulties I’d been having. I’m going to try again when the rep calls in response to my request last night to really get someone working on this, and in the meantime, my doctor is now working on the PA.
@Pianoplayer7008 Don’t make this more complicated than necessary. UHC covers CGM, or they have at least covered it in the past for me.
Call the DME you were referred to by Dexcom. Have them fax a CMN to your doc, verify they have your correct diagnosis code from your doc, and your insurance information. As soon as they have everything they need they will submit to UHC and you will get your Dexcom.
Believe me, the DME provider really wants you to get your stuff, it’s the only way they get paid.
Either the DME rep I talked to was clueless or lazy, but I talked to her a couple times, and she couldn’t get anywhere, either. Finally told me if I ever changed insurances (I mentioned some things were changing with my husband’s company), she’d be happy to help.
Emily,
I’ve done this before. You can get this. But you have to setup your appeal with a bit of legalese.
If you have to appeal this, here is an example of what you need to do. Get a copy of your SPD (Summary Plan Description).
Look through it. Here is an example of covered prescription drugs:
Covered Prescription Drugs. The prescription drug program covers drugs that require a physician’s written prescription and are Medically Necessary for the treatment of accidental injury, sickness, pregnancy or the prevention of pregnancy. blah blah blah…
What’s Not Covered: Prescription Drugs —See Appendix A.
Now we go to have a look at Appendix A.
APPENDIX A What’s Not Covered: Prescription Drugs
The prescription drug program covers Medically Necessary medication. It does not cover charges for:
Prescription drugs for any condition, injury, sickness or mental illness arising out of or in the course of employment for which benefits are provided under workers’ compensation law or other similar laws, whether or not a claim for such benefits is made or payment or benefits are received Your coinsurance or copayment amount
blah blah blah
Charges for cosmetic, dietary supplements, and health and beauty aids.
blah blah blah
Durable medical equipment, prescribed and non-prescribed outpatient supplies other than diabetic supplies which are covered under the medical portion of the Plan described in Article VII.
So you have to weave back and forth through the SPD, and look for anything that says CGM is not covered. It takes a while but you should be able to build a solid path through the SPD and see that nothing in there denies it.
You can also request a policy statement from UHC that explains their CGM coverage. I got one from them. It is covered.
Anything not explicitly denied should be considered as being covered.
