# Insurer Medical Policies, Big Picture
**URL:** https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807
**Category:** Insurance
**Tags:** cgm
**Created:** [December 13, 2018, 6:53pm UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807 "2018-12-13T18:53:32Z")
**Posts on this page:** 20
**Page:** 1
### Author:  [@John58](https://forum.fudiabetes.org/u/John58)
#### Post date: [December 13, 2018, 6:53pm UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/1 "2018-12-13T18:53:32Z")
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.
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### Author:  [@Thomas](https://forum.fudiabetes.org/u/Thomas)
#### Post date: [December 13, 2018, 8:46pm UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/2 "2018-12-13T20:46:57Z")
@John58
We did have to provide justification for the cgm when we first went on it.
I was very careful in my wording.
I don’t recall the exact phrasing but did consider quite carefully before I provided it.
In essence, I said that nighttime hypoglycemic symptoms while sleeping are not physically recognized and waking does not occur. The cgm is required to alert and wake at nighttime so as to be able treat and prevent sustained nighttime lows that otherwise may require emergency medical intervention so as to possibly include an ambulance transport and stabilization in a critical care Emergency Room.
I totally get what they are saying about a convenience item as well as the portion about not being on insulin. As odd as it may sound, I have no doubt there would be no shortage of people without any diabetes diagnosis who would request a cgm from the insurance company so they could monitor their BG to make sure to keep it in range. Not even a shred of a doubt this would occur.
So any change in policy has to still account for the wack-a-doodles (is it ok to use that term? lol.) who are intent on making it harder for the people who actually have valid and medical reasons for a cgm system.
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### Author:  [@Sam](https://forum.fudiabetes.org/u/Sam)
#### Post date: [December 13, 2018, 9:03pm UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/3 "2018-12-13T21:03:47Z")
> [@Thomas](#):
>
> As odd as it may sound, I have no doubt there would be no shortage of people without any diabetes diagnosis who would request a cgm from the insurance company so they could monitor their BG to make sure to keep it in range. Not even a shred of a doubt this would occur.
Not a shred of doubt here either. I can’t even begin to count the number of non diabetics who’ve regaled me with lengthy discussions of their struggles with their blood sugars… they’d be in hog heaven with a cgm, either that or their hypochondria would just escalate even further— which is more likely…
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### Author:  [@Thomas](https://forum.fudiabetes.org/u/Thomas)
#### Post date: [December 13, 2018, 9:06pm UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/4 "2018-12-13T21:06:34Z")
> [@Sam](#):
>
> or their hypochondria would just escalate even further— which is more likely
Yeah - for sure !!!
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### Author:  [@John58](https://forum.fudiabetes.org/u/John58)
#### Post date: [December 13, 2018, 9:08pm UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/5 "2018-12-13T21:08:45Z")
I’ve been through the process for CGM a few years ago and eventually got it approved (after wading through red tape, appeals, insurance company “losing” documents, etc.) and I agree that insurers must have a policy. My gripe is that the policy is too restrictive. I especially don’t like that non-compliance loophole in the policy. The cynic in me says somebody could get stuck in a rabbithole on that. I guess I’m worried about all the people who need a CGM but are not able to wade through the pre-authorization roadblocks and wondering what course of action would have a remote chance of causing the insurer to loosen things up. Personally I think anybody injecting insulin will have better outcomes and avoid danger by using a CGM and the insurer need to be forced to acknowledge that in their medical policies.
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### Author:  [@Sam](https://forum.fudiabetes.org/u/Sam)
#### Post date: [December 13, 2018, 9:10pm UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/6 "2018-12-13T21:10:51Z")
I agree it should be that simple for t1—- if you’re using insulin you should qualify for cgm without exception.
I don’t know enough about what life with t2 is like to know if that should apply there too or not.
I’d also offer that there’s no reason for someone not on insulin to be using a cgm. It makes no sense.
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### Author:  [@Thomas](https://forum.fudiabetes.org/u/Thomas)
#### Post date: [December 13, 2018, 9:14pm UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/7 "2018-12-13T21:14:54Z")
> [@John58](#):
>
> 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?
I saw this months ago from UHC. If there was an update, it was extremely minor as the gist of the Senseonics being “investigational” was in place prior to November.
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### Author:  [@Thomas](https://forum.fudiabetes.org/u/Thomas)
#### Post date: [December 13, 2018, 9:19pm UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/8 "2018-12-13T21:19:41Z")
> [@Sam](#):
>
> I don’t know enough about what life with t2 is like to know if that should apply there too or not.
If the T2 is on bolus and basal insulin then IMHO they should be treated in this respect no different from a T1.
Dexcom is working on a cgm which will have a low enough cost to be applicable for T2 who are not on bolus and basal insulin. Dexcom calls this the “second generation disposable Verily device” which is “on track” for a late 2020 or early 2021 commercial release. (Per Dexcom).
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### Author:  [@John58](https://forum.fudiabetes.org/u/John58)
#### Post date: [December 13, 2018, 9:29pm UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/9 "2018-12-13T21:29:47Z")
Admittedly the Eversense would be a convenience for me…due to the alerts occurring without using a receiver. That is why I dropped out of further appeals.
But my big picture question is still out there: does the grievance process at an insurer ever result in changing a medical policy? Does a state insurance commissioner have any power to enforce changes to insurers policies?
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### Author:  [@Thomas](https://forum.fudiabetes.org/u/Thomas)
#### Post date: [December 13, 2018, 9:49pm UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/10 "2018-12-13T21:49:17Z")
> [@John58](#):
>
> But my big picture question is still out there: does the grievance process at an insurer ever result in changing a medical policy?
I am better at details than “Big Picture” kinda stuff.
😛
But good luck with it and hope it all works out for you one way or another.
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### Author:  [@Chris](https://forum.fudiabetes.org/u/Chris)
#### Post date: [December 13, 2018, 9:56pm UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/11 "2018-12-13T21:56:19Z")
@John58, I don’t think a single patient going through the grievance process has much if any impact on an insurer making changes. With that said, if a large number of patients go through the grievance process, I would think that would have an impact.
Unfortunately, the grievance process is quite painful and frustrating based on my experience. Additionally, after we began the process of appealing to the outside physician, the company I was dealing with changed their policy to include my son in the new covered list. I truly believe this was incidental i.e. my appeal didn’t spur any action.
I think you would have as good an outcome if you located one of the insurance board members that sets and votes on the policy and lobbied them directly.
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### Author:  [@Katers87](https://forum.fudiabetes.org/u/Katers87)
#### Post date: [December 13, 2018, 10:03pm UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/12 "2018-12-13T22:03:08Z")
Are you getting this insurance through your employer? Is it a large company? Some companies have an appeals process that might enable a change in policy. It’s not common, but it exists.
> [@Chris](#):
>
> I don’t think a single patient going through the grievance process has much if any impact on an insurer making changes.
I agree with Chris. There’s a chance you may be able to convince them to make an exception for you, but I think you’d be hard pressed to prove that the Eversense is medically necessary because it provides a benefit that the Dexcom doesn’t. It’s fairly new, so maybe it will be covered in time.
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### Author:  [@John58](https://forum.fudiabetes.org/u/John58)
#### Post date: [December 13, 2018, 10:19pm UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/13 "2018-12-13T22:19:17Z")
My goal is not to get coverage for myself, I have been through the process and am covered for the Dexcom…I am willing to accept their policy regarding the Eversense but found it fishy that they wrote in that part of the policy after I appealed.
My goal is to get them to change their medical policy so insureds using insulin do not have to jump through all these hoops (that I cynically believe are intended to cause patients to give up and drop appeals) to get a CGM covered for everybody who actually needs one. Donating money to the ADA or my congresspeople will not accomplish this in my opinion.
Its a long story on this insurance. I owned a small business and signed the monthly checks to this carrier starting in 2012. I am now partly retired but still on the same company plan. This is a small biz with no HR department, I am no longer in charge but am a consultant to the company. I have reached out to the sales people at the insurer, who know me and are motivated to help, but they are powerless to change a medical policy.
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### Author:  [@MM2](https://forum.fudiabetes.org/u/MM2)
#### Post date: [December 14, 2018, 2:02am UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/14 "2018-12-14T02:02:38Z")
> [@John58](#):
>
> 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:
Does this assume approval for person who is not already using pump?
Not clear on reference to criteria A or B or C with multiple upper and lower case notations.
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### Author:  [@Sensorium139](https://forum.fudiabetes.org/u/Sensorium139)
#### Post date: [December 14, 2018, 3:12am UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/15 "2018-12-14T03:12:36Z")
This is pretty much how it is on medicaid, and I currently can’t get better coverage (Can’t seem to get full time at my current job, don’t wanna switch I like this one too much and it’s a nice job after my last one being so horrible, only hope is if my fiance gets better coverage other than medicaid himself we can get something better). I wish it wasn’t this way because I’ve been like dreaming of trying a CGM to see if it truly would make me anxious or help me see the whole picture. My a1c went from 5.8% to 6.1% in 6 months and I want to know why. I have no real idea even when I do take my time and money to buy more test strips and test like upward to 10 times a day to try to figure it out and it gives me no insight vs the usual amount I test (I rarely test low or high at all…so I only test 3-4 times a day most the time , rarely more but never less) nothing has really changed since I got my last a1c as that was when I started my new job and my stress level died down a lot from being unemployed and life has been good, I haven’t really changed my eating habits any different than before. I have to basically screw up in some way or another apparently to get a CGM it seems? I don’t want to do that so I have to try to figure it out without a cgm and it’s a harder thing than I wanna deal with. My only other real option is like either try to pay out of pocket (most my income prolly) towards a freestyle libre which I’ll have to try to get without it instantly going through my medicaid and giving me a headache when my doc sends it in for the rx that it requires, or maybe the grey/black market?
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### Author:  [@Katers87](https://forum.fudiabetes.org/u/Katers87)
#### Post date: [December 14, 2018, 4:55am UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/16 "2018-12-14T04:55:30Z")
> [@John58](#):
>
> My goal is to get them to change their medical policy so insureds using insulin do not have to jump through all these hoops
I thinking running for office might be the best option…
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### Author:  [@John58](https://forum.fudiabetes.org/u/John58)
#### Post date: [December 14, 2018, 5:30pm UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/17 "2018-12-14T17:30:11Z")
Ha, wait till the press dredges up my social media and discovers I’m a chronic griper! That’s the #1 qualification fir elected office, isn’t it?
Actually I think I’ll get in touch with the state insurance commissioners office and see if I can review records from their review/approval of insurance company’s medical policies regarding CGM, any complaints they looked into, see how it went, did it result in a better (for the patient) coverage decision, etc.
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### Author:  [@elver](https://forum.fudiabetes.org/u/elver)
#### Post date: [December 14, 2018, 8:24pm UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/18 "2018-12-14T20:24:21Z")
@John58 I used hypo unawareness to win my appeal (with significant help from my awesome Endo). I was initially denied twice.
Regarding Senseonics… I would crunch the numbers. There are studies out there that attempt to claim a large non-compliance rate for cgm. Use after 90 days. The implant would negate that, encouraging patient compliance and saving $$ in the long term. I would also demonstrate the cost benefits of implant VS dexcom/Medtronic if any to help my appeal
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### Author:  [@John58](https://forum.fudiabetes.org/u/John58)
#### Post date: [December 14, 2018, 9:07pm UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/19 "2018-12-14T21:07:33Z")
Good ideas for anybody working on an appeal…although I’m not sure I understand the points about non compliance with CGM usage. Do you mean people are getting CGM coverage from their insurance and then selling the CGM or otherwise not wearing it? If that’s happening I guess it’s on the insurance company’s shoulders to audit usage or something and handle on a case by case. Not ration out CGM’s to everybody to try and cut their losses.
I’m still mulling over the bigger picture goal which is to get the state to regulate the insurers…by making them change their medical policy regarding CGM coverage. Ultimately my state’s insurance commisioner has the authority to do this. I want them to redefine “medical necessity” in insurance red tape world as anybody injecting insulin needs a CGM as a safety measure and eliminate all the extraneous requirements that the insurers rely on to deny coverage. They cover the insulin, they need to cover the CGM’s.
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### Author:  [@Thomas](https://forum.fudiabetes.org/u/Thomas)
#### Post date: [December 15, 2018, 12:29am UTC](https://forum.fudiabetes.org/t/insurer-medical-policies-big-picture/5807/20 "2018-12-15T00:29:52Z")
@John58
Which part of the insurance policy are you objecting to?
Not arguing rather I just lost track.
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