I was really hoping to get on a CGM this year. Dexcom I saying my insurance will not cover it , since my control is to good. I guess they want to see that you are testing at least 8 times a day , and are going under 50 bg and over 250 on a regular basis.
I eat a low carb diet and have an ac1 of 5.2, and just don’t see those numbers. Dexcom keep telling me to submit written bg charts, which sounds like them telling me to fudge the numbers. This isn’t something I am going to do. It immoral , and I wonder if it could look bad at some point that I’m claiming my bg is out of control. I drive for a living now, so it seems like a bad idea to say I’m out of control.
Not sure who you are talking to at Dexcom, but it is the insurance company that decides it, not Dexcom.
I don’t know of any requirement for bad control in order to get coverage for a CGM. There are some requirements I have seen for certain insurance companies that won’t cover a pump unless your A1C is above a certain number, but I have not seen it for a CGM yet.
Have you talked to your insurance company about it yet? Do you have a copy of your insurance Summary Plan Description (SPD)?
My insurance, as well as many others, absolutely requires problematic control, specifically regular risk of severe hypos (40s or lower) to cover a CGM.
I respect that—it’s what many people end up doing though, and that is indeed what they are hinting at. I would suggest trying to get over the morality thing, except that I see your concerns about the driving component… that does put you in a rough spot.
As has been mentioned, I would start talking directly to the insurance company. I would appeal, perhaps on a basis of early detection of lows while driving. I myself, would not fudge the numbers, even though that may be the path of least resistance.
Just want to point out a few things. The OP didn’t state he had already been denied. He wrote that Dexcom is saying insurance won’t cover it. Dexcom is not the insurance company. They may have experience with particular insurance companies, but they probably don’t have the SPD, and certainly they are not the ones approving it or denying it.
What Dexcom says about this is irrelevant. If Dexcom is telling him to submit BG records before he has even applied for it and been denied, that is silly. And it is wrong. You need to get denied before anything like that happens.
To go one step further, I wouldn’t even bother talking to someone with the insurance company before applying, because until it is denied it is merely speculating on what will happen.
What Dean should do is try to get it and see if it is denied. If it is denied, then he can consider what is needed to appeal.
And @Dean, if you do get denied, you should appeal. And as far as the BG records, you don’t need to fudge anything. Any BG test below 70 is considered hypoglycemia. All you have to do is get to 68 and test like crazy. Test as many times as you can when you are below 70. You can easily test 3 or 4 times every single time you are below 70. Fill up your meter with “hypos”, bring it to the endo’s office and let them pull the numbers from your meter and submit the appeal. You will have a meter full of tests that are considered “hypo”, even if they are not really that low.
No lying is necessary. And your appeal should state that you drive for a living and mention the risk.
If you get denied, this would be an easy one to win. I’ll help you if you need it.
Do you have T2 diabetes? Or do you have T1-LADA? It seems unlikely that a juvenile-diagnosed T1 would not see BG under 50 or above 250 when testing only a few times a day. Insurance companies do put restrictions on CGMs for T2s, and if that is your case then you will have to work with your doctor who needs to be convinced that it is necessary for you so that he will fill out the necessary additional paperwork. (Eric is absolutely right that the fact that you drive for a living should make this an easier argument to make). If you are a newly diagnosed T1-LADA, then it will be easier for you to get covered, though you will still need your doctor’s help for that.
But I think this begs the question of why you so badly want this technology when it seems like you don’t really need it? A1c of 5.2, infrequent BG tests, and no large BG swings indicates maybe you really don’t. If so, then why not enjoy the time you can have without this additional hardware hanging off of you? Why not put it off until your control is worse and you really need it?
Dean, I will add that I went through multiple appeals with my insurance to get CGM covered and finally got approved once I got a copy of the “medical policy” document that my insurance company uses. Every insurer has a policy, and they are not all the same.
Initial appeals included BG logs and a letter noting that the demands of my job at the time required CGM. (Example: drive all morning to a remote site, climb around on a landslide all day, drive home at night). These were denied.
I finally got the insurance company to send me their “Medical Policy” document. The next appeal specifically referenced the criteria listed in the medical policy. These criteria were: “Unexplained large fluctuations in daily pre-prandial glucose values… Unexplained frequent hypoglycemic attacks” among other things. I sent them a boatload of BG meter logs, noted low BG in the letter and highlighted on the logs, and was approved. The way things were going for me at the time, I had several actual BG readings below 50 and did not cheat.
In hindsight, I could have gotten CGM approved quicker if I had obtained and referenced the medical policy document at the initial request for coverage. Your insurer will have specific language in the medical policy. You should request that document and see what it says. It took me multiple phone calls to get them to send it to me.
When getting our Dexcom approved, I was not sure what would make a difference and what would not.
I had an “interview” with somebody from the insurance company. They asked multiple times if low blood sugars were detected and felt internally. Each time, I truthfully answered that low blood sugars are NOT felt during nighttime while sleeping. (And chose to simply ignore the daytime aspect and not address that.) Although I was well aware they wanted to know if they were “felt” during the daytime - as they were only insinuating that, I felt it totally appropriate to answer the question as I felt it should have been asked.
I see nothing wrong with driving the “interview” in the direction YOU want it go to regardless of how THEY want it to go. I am certainly not going to bullshit them but on the other hand, I will provide what information I think is particularly relevant even if that is not exactly what they are asking.
If my T1 was of driving age, I would have also stressed the importance of having CGM monitor WITH alerts while driving so as to provide a safe driving experience not only for everybody in THIS car but also all the other cars in the vicinity. They might not ask - but I would certainly provide that. It is accurate and truthful. Even if that is not what the health insurance company is asking about - it is life.
Bear in mind that there are a whole s-load of T1’s who drive without a CGM (in fact most do, since CGMs are still relatively rare especially outside the US). Nevermind the CGM - lots of us learned to drive back before there were even BG tests. So arguing that a CGM is medically necessary for a diabetic to be able to drive is not going to hold water since the vast majority of diabetics drive safely without wearing a CGM. The argument has to be that a particular diabetic cannot keep their BG in a safe range while driving without it going low unexpectedly and to dangerous levels.
If your insurance formally denies coverage then you can go to the next step of the appeal process in which your doctor might have to clarify why it’s medically necessary for you. If it’s just hearsay from dexcom I wouldn’t take it too seriously…
If someone is hypoglycemic unaware, then that should be sufficient to claim the need for a CGM regardless of whether they drive. And in fact that is similar to what the OP wrote he was asked to do - provide some evidence (that the OP said he couldn’t supply) that his BG was volatile to dangerous levels. Which is also what John said he did in order to get covered for his CGM:
And back to what you wrote:
This sounds to me like a slippery slope. Would you support the idea that only Type1’s who wear CGMs should be allowed to drive? I certainly would not.
I was diagnosed as a Type 1 at age 37, 2 years ago. I have a good A1C with little testing because of my restriction of carbs. I’m but I am getting burnt out on Low Carb, and would like to start eating slightly more carbs, but I am unwilling to give up my tight control over BG. Also CGMs, dont seem like additional hardware hanging off me, this is how I view a pump. Inserting a CGM seems easier and faster then multiple finger pricks a day.
One thing to note is that if the insurance company doesn’t want to pay for it, you can pay for it yourself. I’ve had good luck getting discounts when paying for things out of pocket.
My dentist gives a 20% discount for people who aren’t paying through insurance and I’ve had a dentist charge me for a simpler procedure than what they actually did since I was paying out of pocket. Once my wife had to go to the hospital but we didn’t realize that the insurance company had just stopped covering that hospital, so we were stuck with an $8000 hospital bill; when the hospital found out that we didn’t have insurance they cut the price by 50% and let us pay it off over 6 months (without interest or fees).
I don’t know if Dexcom will let you pay less, but it can’t hurt to ask. If you pay for your medical expenses with an HSA (or maybe an FSA) then you pay tax-free which effectively reduces your cost even more (10%-39% depending on your tax bracket).
Part of that is because the insurance companies almost never have to pay anything close to full price anyway, so it’s not like they are normally expecting to get the full price. It’s misleading what you see hospital expenses listed as. Sometimes they won’t give as good discounts to individuals as insurance companies though (since you as an individual have much less bargaining power), and that’s a big part of why the insurance system screws anyone not insured.
Totally. Some (many? most?) countries negotiate prices on behalf of all citizens which gives them quite a bit of bargaining power.
Speaking of paying out of pocket, I’ve had good luck with GoodRx which provides prescription discounts at various pharmacies, sometimes for less than your insurance co-pay. (If you have a high co-pay.) Doesn’t seem to offer Dexcom sensors though