Insurance denied a CGM device for a 5 year old.. Need help for appeal letter


(Fred) #1

I received a deniel letter today from Blue Cross Blue Shield of NC for a CGM device (Continuos Glucose Monitor) for my 5 year old daughter. Reason for denial: Not Medically Necessary.  It also says "In this case, records do not indicate the presence of severe, symptomatic hypoglycemia." What is considered severe? Luckily we have been fortunate not to have any major episodes (knock on wood), but she has had her share of highs and lows and will be beginning full day school in the fall.

 I am so furious, ready to write my letter of appeal, but I think it would be wise to calm down first and ask for some advice on what appoach to take, rather than say to them what I really want to...

If any one has been approved, can you please give any information that may have helped you to get approved. Any example letters would be greatly appreciated and would also help others going through this same problem.

Thanks for any help!!

Fred


(kbuckleync) #2

Hi Fred:

I, myself, was on BCBS of NC when I first moved to NC 6 years ago.  They're the worst.  They were horrible to deal with.  One thing you might want to try is having the CGM company, whichever one you chose, deal directly with the insurance co.  Most pump and CGM companies have an insurance rep who deals with that sort of thing.  That's how I ended up getting both my pump and my CGM.  Although I'm with Aetna now.

Before you bother with the appeal letter, try that route.  The CGM company will also be able to tell you what sort of lucky they've had with BCBS of NC.

Good luck!


(Fred) #3

Thanks for your reply..  The CGM company is the one that applied for me. Still trying to contact them. Must be closed today.. not answering the phone. I was  wondering what company did you get your CGM through? I don't even know if I can change companies, since the other one was denied. Maybe they have better luck.

My daughter is on the Medtronic pump.

Thanks,

Fred


(thawkins) #4

We are in the process of applying for coverage for a CGM for my three year old daughter, and the rep from Dexcom told us insurance will often deny unless you show three at least three lows in a week, defined as below 50. This struck us as pretty severe - we try not to let our daughter get that low that often! Anyway, the rep drafted a letter for us, although we haven't heard back yet. You may try having your rep draft an appeal letter.

Good luck!


(Fred) #5

Hooray!!!!  We were approved today.. Just in time for school.  Persistency paid off. Should have the CGM by next week.


(diabeticcowgirl) #6

The thing that helped me get my continuous glucose sensor was my Doctor yelling at my insurance company.  Getting the Dr to write the company a letter is the best thing you can do for approval.  My dr. yelled at them orignally because they only wanted to cover 50 test strips a month and at the time i was testing at least 8 times a day...56 times a week.  So he yelled at them over that then magically my pump approval went through without a problem a few weeks later....lol


(Gina) #7

Fred,

Congrats! It took me a year of fighting to get mine covered! I even started a petition and website about it here: http://cgm-antidenial.ning.com


(kbuckleync) #8

Hi Fred: Which CGM did you end up getting for your child? My friend, who also has BCBS of NC got denied for her CGM, and she's been paying for it out of pocket.  I'll tell her that you suceeded, and maybe she'll be interested in trying again.


(Gina) #9

Kristen, tell your friend to keep fighting DON'T PAY OUT OF POCKET YET! Persistence works I promise.


(kbuckleync) #10

Unforunately she's already been paying out of pocket.  They covered her for a while just recently, when she was pregnant.  But now that she's had the baby they stopped paying again.  Does she just need to appeal?


(Brittany) #11

That is pretty sorry right there. I'm glad I don't have BCBS of NC. My dad had BCBS of Michigan. They said if I was on BCBS of NC I would have had to wait for 5 years to get a pump. Suposivly mine wasn't severe enough. How severe does it have to be? Do you have to be dead??? I can't help you to much. I'm really sorry about your daughter not being able to get a CGM. Maybe if you send a letter and keep complaining they will do something. Maybe if they get enough complaints they will do something about it.