Just to validate they didn’t make a mistake, make sure this is the procedure code they are showing:
A9276 - Sensor; invasive (e.g. subcutaneous), disposable, for use with interstitial continuous glucose monitoring system
2 Likes
Thanks. Is that just for the sensors (and there’s a different code for the transmitter)? I think that’s part of where the confusion is coming from - one person I’ve talked to through the pharmacy coverage has said they don’t provide the system, despite the fact that my policy specifically says that’s where I’m supposed to get it.
Procedure Code: a9278 - Receiver
Procedure Code: a9277 - Transmitter
Procedure Code: a9276 - Sensors
2 Likes
Thank you! And thanks all - I just relayed all of your suggestions to my husband, who said he knows exactly what y’all are talking about, as he’s had to do these kinds of things for patients before, so I guess we have a plan now. Y’all are awesome!
1 Like
What does he do?
Just make sure the underlying diagnostic codes they’re billing you with historically are correct for t1 too… that’s a biggie I’m thinking
2 Likes
He’s an RN at a local hospital.
Cool, my wife’s an RN as well, soon to be DNP
1 Like
Nice! He’s hoping to go that route eventually - about to start working on his bachelor’s right now though.
2 Likes
Phenomenal career… must admit I’m jealous at times
1 Like
It is pretty amazing. I almost tried for an RN degree in college (then was going to go on to be a CNM), but I decided to just be a mom instead (thankfully…as my health has deteriorated, it would be impossible to manage both a career and mothering).
2 Likes
I have no idea how she manages it all, especially with me working away from home
1 Like
Do you have an employer based plan ? If yes, is there documentation showing CGM covered as pharmacy ? Try calling Foundation Care, they can bill as pharmacy. I used them before for my dexcom, and they are great.
Now my dexcom is covered as DME, so I use Byram. Byram may be billing yours wrong, or not able to process as pharmacy.
1 Like
Have you called Wilford Brimley?
Hello.
I have type 2 diabetes and use insulin. UHC denied my doctor’s prescription/recommendation for a CGM. It was based solely on the fact that I am type 2. I appealed all the way to the state level (California) and prevailed. After six months of using the Dexcom 5, my a1c dropped from 7.2 to 6.4.
Let me know if you want additional information.
David
7 Likes
@dr.intrepid
That is awesome. Quite the persistence. UHC may very well change their overall policy in regards to this.
1 Like
That’s great news @dr.intrepid. We could all be interested in learning your path to approval for the CGM.
It’s my opinion that anyone who takes insulin should be eligible to get a CGM. It’s very shortsighted and ignorant of the insurance companies to deny a CGM to anyone taking insulin, whether T1, T2, or T50.
And Welcome to FUD!
1 Like
Wow, I would love to hear more. I’ve temporarily stopped fighting, as I picked up a FreeStyle Libre to try for now, but I will want a Dexcom in the future!
2 Likes
I live in California and have United Healthcare HMO. In CA , there is an appeals process. The process includes the standard two step appeals process managed by the HMO. If the HMO determines that durable medical equipment (in this case the CGM) is not medically necessary, one can file for an Independent Medical Review. If the IMR doctor rules against the HMO, then they must provide the DME as prescribed.
I am type 2 insulin dependent. I was injecting 3-4 times per day and conducting 3-4 self-tests per day. According to UHC, I met the medical necessity criteria in all areas except for the fact that my diabetes was type 2. UHC’s denial was based solely on the fact of my type 2 diagnosis. Per UHC, CGMs were not medically necessary as there was a lack of research that showed the efficacy of the use of a CGM with type 2s (note: UHC continues to use that argument in their denials for CGMs, even though there is now more research that is supports the use of CGMs in reducing overall a1c and reducing hypo and hyper events. When I submitted that research, UHC indicated that the studies that I submitted were not randomized and peer reviewed).
The IMR was conducted by a board certified endocrinologist. In ruling against the HMO’s decision he cited the following factors as evidence of the medical necessity of the CGM:
-
There was new research and recommendations for the use of CGMs for insulin dependent type 2s
-
That I was insulin dependent (I use both long acting and short acting insulin). I needed to administer my insulin 3 or more times per day
-
My doctor’s records indicated that I was compliant with the management of my medication, including insulin.
-
I had previously participated in diabetes education and consulted with a dietitian.
-
I was checking my blood glucose levels 3 to 4 times per day
-
I continued to experience hypo events and postprandial highs (in spite of the above mentioned interventions).
-
Being type 2 really did not count for much. In the IMR doctor’s view, type 1 interventions should be considered and utilized where needed.
The result of IMR finding (which occurred in February 2016) was that within two weeks, UHC provided me with a Dexcom 5. For what it’s worth, My December 2015 a1c was 7.2. My June 2016 a1c was 6.4 (after only having the CGM for three months).
I am entering my third year with the Dexcom 5. It has become an essential device in my treatment of my diabetes. I know that a CGM is not for everyone. I also know that all situations are unique. However, I hope that this information may be of some help. Please let me know if you have any other questions or need additional information.
Regards,
David
7 Likes
UHC is very particular about diagnosis codes. I had a doctor use a slightly different code than was needed once, and UHC denied the claim with an explanation along the lines of “not covered.” When I called UHC, they said the benefit wasn’t covered under that diagnosis code. I asked them under which diagnosis code this benefit was covered, and they told me. I had my doctor correct the diagnosis code, and UHC paid the claim. It sounds so simple now, but it was actually a big headache because it took me awhile to figure out what the problem was. This was for a non-diabetes related benefit, but my recent DME order lists an ICD-10 diagnosis code of “E10.9: Type 1 diabetes mellitus without complications”. There are likely a few different type 1 codes.
I think UHC is a huge hassle in terms of getting things covered. They seem to be unnecessarily particular, and I suspect they’re just weeding out the people who won’t fight them on bills… perhaps I’m being overly critical. The good news is that once you figure out how to get the Dexcom supplies covered, you generally just need to maintain the status quo after that.
Carecentrix facilitates my Dexcom supply order, but the supplies are shipped directly from Dexcom. This has worked well for me, but I don’t think UHC uses Carecentrix. Since I started using Dexcom, I haven’t had any trouble getting it covered (first with Kaiser, then with Cigna). This makes me wonder if your diagnosis is coded wrong (as gestational or type 2). Though some insurance plans are simply more/less generous than others. I really hope you can get it covered 
It’s been so incredibly helpful to me.
Also, I have always ordered my Dexcom supplies and pump supplies (not insulin) under the DME benefit - Durable Medical Equipment (though most of this supplies is disposable so I think that’s an idiotic term to use). Generally this means cost-sharing through coinsurance (% of total) instead of co-pays (defined $ amount regardless of total).
Also, I personally consider $150 for a box of pens to be a decent sized bill. If your plan offers a 90-day mail-order program, sometimes you can get better benefits by using it. For instance, my plan has a 30% coinsurance for a 30-day supply of brand-name drugs bought in a pharmacy, but I can get a 90-day supply (I think 4 boxes of pens) of brand-name drugs through mail order for a defined total co-pay of $65. Not all plans are structured like this, but you can save a lot of money if your plan is.
Also, also, also… hehehe
2 Likes
In another thread, @kirbywright was talking about his insurance problems, and I have a current one which is playing out as we speak. So I found this old thread on the same topic and I thought I would resurrect it, as there is some interesting info there.
In my insurer, which is Tufts Health, they have recently required prior approval from a doctor. Ok, that works. But when my endo submitted his forms this time, they rejected, because they want me to move to a Freestyle Libre. I had to call them to find out the reason for rejection, but I understand it – the libre is probably less expensive than the Dexcom.
Unfortunately, my Tandem pump only works with the Dexcom so we will have to appeal. Stay tuned …
2 Likes