What is the best strategy an individual can take to push insurance companies into more realistic medical polices regarding CGM coverage for Type 1 diabetes? Is it going through the grievance process at the insurance company or going directly to the state insurance commissioner? My complaint is the “medical” policy at my insurer. I have two issues with their medical policy. My number one concern is their medical policy regarding CGM coverage for adult Type 1’s:
Personal long-term FDA-approved CGM devices and related accessories and supplies may be considered medically necessary and covered when an individual undergoes the completion of a diabetes self-management education program and any one of the following criteria (A. or B. or C.) are met:
A. Adults (25 years or older) with type 1 diabetes who meet both of the following criteria (1. and 2.):
1. Documented history of inadequate glycemic control, as indicated by both of the following:
a. Compliance with frequent self-monitoring (4 or more fingersticks per day); and
b. Either insulin injections (3 or more times per day) or a medically necessary insulin pump are used for maintenance of blood sugar control; and
2. Any of the following criteria is met:
a. HbA1c measurements of 7.0% and greater; or
b. Recurring episodes (two or more events) of clinically significant hypoglycemia (less than 54 mg/dl).
They go further to state:
Use of a long-term CGM device and related accessories and supplies are considered not medically necessary and not covered when the above criterion III. is not met, including but not limited to:
A. Type 1 diabetics not on insulin or taking only basal or bid insulin
B. As a convenience item
(How convenient are those alarms at 3AM or when you’re busy with your life??)
Use of a long-term CGM device and related accessories and supplies are considered investigational and not covered in all other situations, including but not limited to:
*Note: This policy does not apply to patients under the age of 2 year for whom long-term CGM use may be considered medically necessary and covered.
A. Non-pregnant adults with type 2 diabetes
B. Individuals with gestational diabetes mellitus (GDM)
C. Children with type 2 diabetes
D. Individuals with compliance issues
(If an individual has recurring hypo’s or an HbA1c above 7.0, wouldn’t some endo’s say they have “compliance issues”??)
Does anybody agree that this policy requires that a patient with HbA1c below 7.0 who diligently avoids low BG below 54 mg/dl must become “non-compliant” with their treatment plan and either (a) drop below 54 mg/dl two or more times at pre-authorization renewal time or (b) drive their HbA1c above 7.0? How does this make any sense? What doctor (other than a bean counter with an MD) would believe such a policy makes sense? Some doctors make such a big deal about their concept of “compliance”…how does that square with a policy like this?
My number two concern is how they view the implantable by Senseonics. The background is that from July to October I attempted to prep my insurer for a pre authorization request by sending them copies of the FDA approval, clinical studies, etc. related to the Eversense. I went through my endo and Byram, submitted pre auth request and was denied Oct. 31. I appealed half heartedly and then dropped it when they sent me their “new” medical policy dated November 2018 that included the following:
Use of CGM devices with an implantable sensor (e.g., EversenseTM by SenseonicsTM) is considered investigational and is not covered for all indications.
My concern with this is it appears that they are reacting to my appeal by pre-emptively updating their medical policy. Are they picking on me? Is this fair play in insurance bean counter world? Did they actually read the clinical studies about the Eversense?
Anyway, I would like to follow this up by elevating my grievance to somebody who might actually force them to loosen up on their CGM coverage. I would like to decide if the insurance company grievance process or the state insurance commissioner is the best way to go so I can focus my efforts. If anybody thinks I am just being a whiner and my grievance will go nowhere please fee free to speak up too.
