Insurer Medical Policies, Big Picture

[John58]

@John58

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).

I think this causes Type 1’s to jump through unnecessary hoops.

[Thomas]

lol - Sorry. I was asking which part.
I will bow out.
No offense.

[John58]

Understood, no offense taken! I realize I have not communicated my concerns clearly at all and probably confused a few people…sorry about that. (I’ve never been the best communicator online). I’ll look deeper into this after the holidays and try to provide an update.

[ClaudnDaye]

@John58

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

I find 1.a and 1.b kind of funny…this is basically saying that doing a, and b makes you fit criteria 1, or, you have “a documented history of inadequate glycemic control.” Well…in my mind, if you’re doing 1a and 1b, you probably have (but most certainly could have) a documented history of adequate glycemic control?

[John58]

I agree, this whole setup allowing insurers to decide whether a CGM is medically necessary (according to them) has made my head spin for a few days. Don’t worry, I’ll get over it.
FYI I reached out via email to my state insurance commissioners office today. Here is what I sent them as an initial inquiry. I plan to follow up after the holidays.

_RCW 48.44.315 was last updated in 2004. Continuous Glucose Monitoring (CGM) devices were invented after that update and are now commonly prescribed for Type 1 Diabetics using insulin. They are often deemed medically necessary by doctors because they provide alarms to prevent dangerous hypoglycemia (low blood sugar). However, health insurers have strict policies regarding CGM coverage that are often used to delay or deny coverage by allowing the health insurer to claim that the CGM is NOT medically necessary. I believe these restrictions on coverage for CGM are dangerous for any diabetic who injects insulin and would like the OIC to require CGM coverage for any diabetic using insulin. _

Has the OIC looked into this and will the OIC consider asking the legislature to update RCW 48.44.315 to address coverage for Continuous Glucose Monitors? My request is that the RCW be updated to state that a CGM is medically necessary (and must be covered) for any diabetic who injects insulin.

[John58]

Well, I’ve still got a lot to learn at my old age…here is the response I got from the state OIC. Looks like I will have to dig in a little deeper and follow a specific process:

Thank you for voicing your concerns regarding CGM devices and medical necessity. Currently, I am not aware of updates in laws or rules regarding CGMs. You have requested the RCW to be updated to require insurers to cover these devices. Our office adopts rules (WAC), which is different from law (RCW). If you would like an RCW updated, you would be best served by contacting our Legislature…

We do, however, have a form on our website if you do have a WAC you would like to see updated. You may petition for adoption, amendment, or repeal of a state administrative rule.