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Tips for getting coverage for CGM
This was posted on the JDRF SITE. I thought it would be helpful to you guys.1
Gina
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STEPS FOR OBTAINING CASE BY CASE COVERAGE FOR CONTINUOUS GLUCOSE MONITORS (CGMs)
Many health plans are waiting for the results of more studies like JDRF's clinical trial on continuous glucose sensors before making broad coverage decisions. However, in the meantime, some health plans are granting individual or case by case coverage. We encourage people who are using or plan to use continuous glucose monitor (CGM) technologies to apply for case by case coverage. Here are a few tips we have obtained from insurance experts that can increase your odds of success.
1. Be prepared and persistent. Seeking case by case coverage is difficult; however insurance companies are granting case by case coverage to some individuals. Make sure to be prepared and to keep trying!
2. Get informed and get help. Read your insurance plan's guide or call your insurance company to learn the proper steps for seeking case by case coverage. Contact your continuous glucose monitor (CGM) manufacturer's customer service staff to see how they can help you. In addition, make sure to include in the paperwork to your health plan the HCPCS codes for CGM devices, which help the health plan to identify and process payments for the technology. The codes for CGM are A9276 for the sensor, A9277 for the transmitter, and A9278 for the receiver.
3. Ask questions. Ask your insurance company if they have a prior authorization policy, an insurance policy that you must have approval before purchasing the device, and satisfy those requirements before asking for coverage. Also, find out what medical equipment suppliers your insurance plan works with and plan to buy your device through them.
4. Communicate the urgency for continuous glucose monitor (CGM) coverage. To better your chances of receiving a positive coverage decision, you must communicate urgency by highlighting health problems and the expenses of acute care. In particular, you will need to provide the following materials to your insurance company:
* Letter of Medical Necessity from your doctor which highlights health problems and your need for continuous glucose monitor (CGM), which may include:
o Documented glycemic control problems (elevated HbA1c, frequents hypoglycemia, hypoglycemia unawareness, overnight hypoglycemia)
o Hospitalizations for hypoglycemia or DKA
o Emergency room visits
o Glucagon administrations
o Diabetes complications, whether early or advanced, such as kidney problems, nerve damage, loss of feeling in feet, and eye problems
* Prescription for continuous glucose monitor (CGM) and sensors from your doctor
* Description of your current care plan (e.g. multiple daily injections or insulin pump, and frequency of self monitoring of blood glucose) and a record of adherence to your care plan from you physician
* Certification that your physician or other provider (e.g. Certified Diabetes Educator) will be supervising your care and maintaining your treatment plan with the addition of continuous glucose monitor (CGM)
* Cite the American Diabetes Association's 2008 Standards of Medical Care in Diabetes which recommends CGM and states that "Continuous glucose monitoring may be a supplemental tool to SMBG for selected patients with type 1 diabetes, especially those with hypoglycemia unawareness."
* Cite current clinical studies which show continuous glucose monitors improve glycemic control. They include:
+ One study found people using CGM spent 26 percent more time each day in their target glucose range, and significantly less time with hyper and hypoglycemia.1
+ Another trial showed that diabetes patients using CGM had a statistically significant drop in HbA1c compared with a control group, and they spent significantly less time below 70 mg/dl and above 190 mg/dl.2
+ An observational study of people using CGM showed a significant reduction in HbA1c in people using CGM.3
+ A fourth study found patients at all A1c levels spent increased time in target glucose ranges when using CGM.4
5. File for case by case coverage. Send the materials to your insurance company.
6. Know your insurance company's appeals process. Since continuous glucose monitor (CGM) is not widely covered by insurers, it is likely that you will be initially denied coverage and you will need to appeal the decision.
7. Submit your appeal. Send the appeal to your insurance plan with the materials outlined above in Step 4 within the timeframe outlined by your insurer.
8. Appeal, appeal, and appeal. The more you appeal each denial, the more you are helping put pressure on insurance companies and make them aware of the demand for coverage of these devices. Don't give up!
9. Please tell us your story! We would love to hear from you on your experiences seeking case by case coverage. Whether you beat the odds and received coverage or are still trying, please share your experiences with us so we can share them with others.
10. Sign up to be a JDRF advocate. Would you like to join with others affected by type 1 to advocate for health coverage for continuous glucose monitors (CGMs) and funds for diabetes research? Click here to sign up to be an advocate.
here is the source
http://www.jdrf.org/index.cfm?fuseaction=home.viewPage&page_id=...
Gina
--------
STEPS FOR OBTAINING CASE BY CASE COVERAGE FOR CONTINUOUS GLUCOSE MONITORS (CGMs)
Many health plans are waiting for the results of more studies like JDRF's clinical trial on continuous glucose sensors before making broad coverage decisions. However, in the meantime, some health plans are granting individual or case by case coverage. We encourage people who are using or plan to use continuous glucose monitor (CGM) technologies to apply for case by case coverage. Here are a few tips we have obtained from insurance experts that can increase your odds of success.
1. Be prepared and persistent. Seeking case by case coverage is difficult; however insurance companies are granting case by case coverage to some individuals. Make sure to be prepared and to keep trying!
2. Get informed and get help. Read your insurance plan's guide or call your insurance company to learn the proper steps for seeking case by case coverage. Contact your continuous glucose monitor (CGM) manufacturer's customer service staff to see how they can help you. In addition, make sure to include in the paperwork to your health plan the HCPCS codes for CGM devices, which help the health plan to identify and process payments for the technology. The codes for CGM are A9276 for the sensor, A9277 for the transmitter, and A9278 for the receiver.
3. Ask questions. Ask your insurance company if they have a prior authorization policy, an insurance policy that you must have approval before purchasing the device, and satisfy those requirements before asking for coverage. Also, find out what medical equipment suppliers your insurance plan works with and plan to buy your device through them.
4. Communicate the urgency for continuous glucose monitor (CGM) coverage. To better your chances of receiving a positive coverage decision, you must communicate urgency by highlighting health problems and the expenses of acute care. In particular, you will need to provide the following materials to your insurance company:
* Letter of Medical Necessity from your doctor which highlights health problems and your need for continuous glucose monitor (CGM), which may include:
o Documented glycemic control problems (elevated HbA1c, frequents hypoglycemia, hypoglycemia unawareness, overnight hypoglycemia)
o Hospitalizations for hypoglycemia or DKA
o Emergency room visits
o Glucagon administrations
o Diabetes complications, whether early or advanced, such as kidney problems, nerve damage, loss of feeling in feet, and eye problems
* Prescription for continuous glucose monitor (CGM) and sensors from your doctor
* Description of your current care plan (e.g. multiple daily injections or insulin pump, and frequency of self monitoring of blood glucose) and a record of adherence to your care plan from you physician
* Certification that your physician or other provider (e.g. Certified Diabetes Educator) will be supervising your care and maintaining your treatment plan with the addition of continuous glucose monitor (CGM)
* Cite the American Diabetes Association's 2008 Standards of Medical Care in Diabetes which recommends CGM and states that "Continuous glucose monitoring may be a supplemental tool to SMBG for selected patients with type 1 diabetes, especially those with hypoglycemia unawareness."
* Cite current clinical studies which show continuous glucose monitors improve glycemic control. They include:
+ One study found people using CGM spent 26 percent more time each day in their target glucose range, and significantly less time with hyper and hypoglycemia.1
+ Another trial showed that diabetes patients using CGM had a statistically significant drop in HbA1c compared with a control group, and they spent significantly less time below 70 mg/dl and above 190 mg/dl.2
+ An observational study of people using CGM showed a significant reduction in HbA1c in people using CGM.3
+ A fourth study found patients at all A1c levels spent increased time in target glucose ranges when using CGM.4
5. File for case by case coverage. Send the materials to your insurance company.
6. Know your insurance company's appeals process. Since continuous glucose monitor (CGM) is not widely covered by insurers, it is likely that you will be initially denied coverage and you will need to appeal the decision.
7. Submit your appeal. Send the appeal to your insurance plan with the materials outlined above in Step 4 within the timeframe outlined by your insurer.
8. Appeal, appeal, and appeal. The more you appeal each denial, the more you are helping put pressure on insurance companies and make them aware of the demand for coverage of these devices. Don't give up!
9. Please tell us your story! We would love to hear from you on your experiences seeking case by case coverage. Whether you beat the odds and received coverage or are still trying, please share your experiences with us so we can share them with others.
10. Sign up to be a JDRF advocate. Would you like to join with others affected by type 1 to advocate for health coverage for continuous glucose monitors (CGMs) and funds for diabetes research? Click here to sign up to be an advocate.
here is the source
http://www.jdrf.org/index.cfm?fuseaction=home.viewPage&page_id=...
Replies to This Discussion
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Permalink Reply by Tim on -
I don't think you can get these CGMs over here in the UK. Will be interesting to find out, so I'll try to post back on here if I come up with anything.
I still get fed up testing my sugars (after 25 years, I'm full of holes), and my GP (doctor) tries to limit the number of glucose strips (Accu-check Active) she prescribes because of budget restrictions, so a CGM sounds like a great idea. I take it they're very expensive themselves, though?!
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