So a few years ago I decided to do something about this inequality. Insurance denies based on a numbers game. They imagine that 8/10 people will not appeal a denial decision, and the remaining 2 who appeal the decision are not competent enough to put up a good argument that is strong enough to sway a plan determination. That’s where I come in. I am a former office manager who dealt with insurance benefits and denials on a daily basis. Specific to diabetes, I have done the research for you for any number of pediatric denial reasons and create an appeal letter for you to use in your fight. Are they 100% effective? No, some insurance companies (I swear) do not seem to read the appeals the first few tries until a third-party eventually (actually) reads it and overrules them. But those insurance companies again are relying on people to give up and not realize that you have multiple attempts at appealing before the final determination comes. Some just have absolutely no benefits for a CGM (more likely with Medicaid products), so you are essentially arguing about something that isn’t offered which is a huge uphill battle and may need to be court-ordered. However, for the majority of (my) appeals completed, they are approved first-try within 30-45 days. What do I charge? Nada. I believe in karma, as well as the device, and know that with every child on a CGM, lives can be saved.
What Is Important to Know for Insurance Denials?
· First, I am here to help! If you are on a private plan and received a denial for a CGM (Dexcom or Enlite) for a patient under 18, please contact me to discuss appeal options. (See below Disclaimer first).
· Most insurance plans allow your doctor to request a peer-to-peer evaluation first. This has to be done prior to any written appeals. Your doctor will have a phone conversation with a medical doctor reviewing the denial, whereas they try to come to terms with why it might be medically necessary to approve the device. This works about 25% of the time, especially when it is for denial reasons such as no evidence of necessity/no evidence of hypoglycemia, etc. Your doctor may be able to give better info than the paperwork or refute that through other means.
· Most states mandate some type of insulin pump coverage. However, they do not specify that it has to be the one you chose. You may need to appeal a specific pump model if they require you to choose the lower cost pump model. This CAN be won, although it may take a lot of appeal attempts. Also, not all insurance companies have come on board with threshold suspend insulin pumps (those labeled artificial pancreas, such as the Medtronic 530g). This device can be very hard to fight a denial on, as it is newer technology and has had some negative press surrounding it. Adults may choose to fight a denial for this, but children under 16 will likely not be approved.
· If you max out on appeals and reach a final determination of not covered, you can start applying for the service/device all over again after the 1 year mark occurs (from the original application). So say you ask for a CGM on June 1st, 2015 and your appeal attempts go through November 28th, 2015. You can apply again, with a fresh new application, for the CGM starting June 1st, 2016.
· State Medicaid plans vary in coverage for Dexcom’s. Generally there are various plans administrators offered per state and they are NOT all the same. If you have state insurance and are denied a CGM, look into the other plan admins. Some do not have any type of coverage for CGM’s while others in the exact same state offer CGM’s with no questions asked. Also, for state and private insurers, medical policies are updated yearly (often middle of the year), so you may not have qualified before (and were denied or told not covered) but are now eligible.
· Some plans need a plan administrator from HR (for work-provided plans) to set up a revised policy condition specifically addressing CGM’s (or pumps) for that plan in order to be approved. No amount of appealing will overrule it if your employer has specifically denied access to the product in question. Only they can revise it, not the insurance.
· You are entitled to know exactly why they are denying, and what information or policies they used in making that determination. You can request to be sent those guidelines/research studies that were used in determining their medical policy on the topic. You may find that they are denying due to a research study or industry recommendation that is 8 years old and has had opposite findings in newer studies/recommendations. Insurance companies only revise policy once per year and are not going to look very hard for better studies when it will cost them additional money to fund more people than before.
· Get your doctor involved. It can only strengthen your appeal to have a doctor’s letter included in your packet.
· You might not have really been “denied”. Review your benefits and correspondence carefully. Sometimes you may have had benefits change from pharmacy to DME (Durable Medical Equipment). So you place your order on February 3rd and they deny payment. What??? Well, your supplier most likely didn’t verify benefits after the first of the new year and catch that you no longer are to receive pharmacy benefits for something they now consider a DME product. It is SO important to verify with your suppliers every new year that an updated benefits determination has been made.
· The top topic I hate is lack of prior authorization. Supplier told you that your system was approved, hurrah! Three months later you receive a bill from the supplier, saying that you have been denied the device that was already mailed to and used by you (or your child). It’s a medical device so you cannot return it which leaves only appealing the insurance denial as an option, but usually they will only pay for everything from approval on, not retroactive. I hate hate this because it is actually the supplier’s fault for issuing the CGM without WRITTEN confirmation of benefits. A lot of benefit determinations are made verbally over the phone with your insurance, where a representative is sitting there looking at a screen with your policy on it. They see that CGM is a covered benefit and relay that info to the supplier. However, they failed to note that deep within the medical guidelines are qualifications for receiving that CGM. Because they didn’t look at the qualifications, they didn’t see that the insurance company actually doesn’t approve CGM’s for kids who are under 8. So while it is a covered benefit for most, it wasn’t for your situation. However, if a proper benefit determination had been made, it would have been caught, the supplier would have told you that it isn’t covered, and a denial letter would have been sent. You could have appealed it and most likely gotten the device within 45 days. There isn’t a ton that can be done for these instances, since the supplier will say that the insurance company didn’t tell them, and the insurance company will state that the written terms of the policy always prevail (over verbal or limited benefits checks). Meanwhile, you have used the system and the supplier expects to be paid. So please double check your medical policies when possible!!
· It isn’t a true denial when you have large copays/deductibles/coinsurance. You might actually be approved for a CGM/Pump but insurance negotiated rates might be $4,000 for a starter kit (example only, every insurance is different). Your deductible is $2,500 and you have 20% coinsurance. This means that you are responsible for $2,500 plus $300 (20%) for a total of $2,800 to get started. Just because you might not be able to afford this does not mean that you are denied, only that you have a plan that makes your out of pocket expenses high.
· If you want to tackle an appeal yourself, take out the personal. Eliminate any emotional pleas, frustrations, or how the device is more convenient. They will not approve devices simply because you might not have to wake up at 2am to do a night-check anymore (convenience). They don’t care if you had to downsize your house to pay for medical care or that you cannot afford to pay for the device on your own (self-pay). The more you make it sound like a mom wrote it instead of your attorney/doctor, the worse off. Use words like “patient” instead of child’s name; “post-prandial” (the after-meal blood glucose); “caregivers” instead of parents/mom/dad/school nurse.
o Example 1: “As the below referenced study in this specific age group is reliable data and postdates any studies used by XYZ Insurance to influence the medical policy guidelines, it can only be surmised that XYZ Insurance is now utilizing outdated and therefore unreliable research in its medical policy when it….(denies due to abc).”
o Example 2: “The caregivers are extremely willing, able and confident in their ability to correctly administer and interpret the CGM data results to manage the patient’s glucose levels within the preferred range (given the right tools).”
o Example 3: “The patient’s age does not lend itself to understanding the scope of this disease or the risks of complications. The patient may be busy and not be in-tune with any symptoms that might arise indicating either high or low blood glucose. This can delay medical treatment and cause a crisis versus being caught early with audible alarms for the child and/or caregivers.”
o Example 4: “Exercise is vital for diabetics but delayed hypoglycemia is a risk. The delay can stretch hours after exercise and cause hypoglycemia. It is impossible to monitor blood glucose values for the full 24 hours post-exercise using manual blood glucose checks. This would necessitate hourly checks to monitor the glucose trend to see when the delayed hypoglycemia might occur. Given that exercise is recommended on a frequent basis for all children, this is impractical.”
My husband is convinced that insurance ruffian’s will be banging on our door for helping overthrow their denials, but oh well! I hope that this has helped you somewhat (or a lot!) in your fight. I encourage EVERYONE to appeal insurance denials.
Disclaimer: This is considered opinion only and any advice/help is not intended to be a guarantee of payment nor replace any legal or medical counsel. Follow your doctors recommendation regarding immediate use of medical devices vs. appealing delays when deciding medical treatment. Purchasing without insurance approval will result in out of pocket costs to the user and this will likely not be reimbursed by the insurance company. Outcomes for any appeal, whether written by blogger Samantha or yourself, are in no way guaranteed and/or promised. All appeal approval or denial decisions are based on your insurance companies policy guidelines and the coverage details from your written policy. There are situations where appealing will not be recommended or able to be completed by the blogger due to personal opinion/experience and/or lack of time. Ultimately it is your decision (along with your doctor) whether you proceed with any level of appeal and should not rest solely on a recommendation made off this site or in other communications. Timeliness of filing is solely the responsibility of the patient. Although I strive to provide appeal writing help in a timely manner, this is in no way a guarantee that an appeal will be written by any certain date, as this is a free service that is provided on a first-come, first-served basis in my free time. If you have emailed me and receive no response within 72 hours, please try again. There is no guarantee that every request will receive my help . At this time, I am currently only reviewing insurance denials from private insurance plans (individual or group) for a CGM or Insulin pump, for Type 1 patients under the age of 18. However, I can occasionally offer comments or limited help to pediatric patients with state insurance (Medicaid) or Type 1 diabetic adults with a private insurance plan. Any copays, deductibles, coinsurance, insurance premiums or other financial outcomes are solely the responsibility of the patient and/or guardian. The device companies and/or suppliers hold all warranties and customer service for the devices. I am not an attorney or doctor, nor an expert of any type; therefore it is the responsibility of the patient and/or guardian to thoroughly review any appeal for accuracy and/or errors before submitting to the insurance. I am not affiliated with any entity, whether for profit or non-profit. Any appeals I create are to be used only for the patient intended and are not to be made available through any other party or for sale. Permission is not granted for any duplication or online posting (Instagram, Reddit, Facebook, discussion forums, third party e-mail or any other online website, host, server, etc).