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
medical 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 and is not guaranteed. 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 harder to fight a denial
on, as it is newer technology and doesn't yet have the million research studies that insurances want to see before they pay out money. You can still appeal but keep in mind that it is based on both CGM and pump technology, so benefits for both need to be in place to have the best level of success.
· 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 Dexcom on June 1st, 2015 and are denied. Appealing may last through November 2015. You can re-apply starting June 2nd, 2016 rather than November 2015 (or not at all).
· 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/providers. 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.
· Sometimes (sad to say), there is no coverage. As in, no coverage ever (or without a court order). This is not due to medical necessity, age, experimental, etc. I liken this to trying to order a burger at KFC. KFC does not have it on the menu. There is no code within KFC's system for a burger. They have no supplier for the beef. But you are demanding a burger. No amount of demanding will make it happen without "management" becoming involved. This is the same as an insurance company who has neglected/abstained from adding the CGM codes to their policy. They don't have the code in their system, it's not on the reimbursement schedule, and they don't have a supplier lined up to provide it. Appealing something that to them, does not exist on paper, is a tall order. There is the slight chance that an appeal will succeed, but that is something that few people are willing to do due to the amount of time involved. (It is easier to switch insurances, talk to HR, crowd-fund, pick up a secondary insurance, etc.) However, if you are not able to switch insurances or self-pay, then give it a try, just be prepared to exhaust your appeal attempts before giving up. 1x appeal/phone call is not going to overcome this barrier, but if you are prepared to put in the work, the chances of success are increased.
· Sometimes (sad to say), there is no coverage. As in, no coverage ever (or without a court order). This is not due to medical necessity, age, experimental, etc. I liken this to trying to order a burger at KFC. KFC does not have it on the menu. There is no code within KFC's system for a burger. They have no supplier for the beef. But you are demanding a burger. No amount of demanding will make it happen without "management" becoming involved. This is the same as an insurance company who has neglected/abstained from adding the CGM codes to their policy. They don't have the code in their system, it's not on the reimbursement schedule, and they don't have a supplier lined up to provide it. Appealing something that to them, does not exist on paper, is a tall order. There is the slight chance that an appeal will succeed, but that is something that few people are willing to do due to the amount of time involved. (It is easier to switch insurances, talk to HR, crowd-fund, pick up a secondary insurance, etc.) However, if you are not able to switch insurances or self-pay, then give it a try, just be prepared to exhaust your appeal attempts before giving up. 1x appeal/phone call is not going to overcome this barrier, but if you are prepared to put in the work, the chances of success are increased.
· 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. (This is a rarer example, it is usually not an issue with the employer).
· Sometimes the supplier gets it wrong. Shocking, I know. A supplier might say that you are denied the CGM or "it's not covered". What they might not continue stating is that it is due to them not having a contract with your insurance and that simply by finding a new supplier, you can be approved. It might be because you no longer have pharmacy coverage but rather DME, and as a pharmacy supplier, they are told no (or vice versa). You may not receive a letter from your insurance stating you were denied. Why? Because likely the supplier verbally heard no when they were making a benefits determination instead of actual application, therefore a denial was never generated by your insurance company. Therefore, you never receive a letter of denial. You should always receive one within a few weeks of "applying", otherwise, there is a strong possibility there was never an official denial by the insurance company.
· Sometimes the supplier gets it wrong. Shocking, I know. A supplier might say that you are denied the CGM or "it's not covered". What they might not continue stating is that it is due to them not having a contract with your insurance and that simply by finding a new supplier, you can be approved. It might be because you no longer have pharmacy coverage but rather DME, and as a pharmacy supplier, they are told no (or vice versa). You may not receive a letter from your insurance stating you were denied. Why? Because likely the supplier verbally heard no when they were making a benefits determination instead of actual application, therefore a denial was never generated by your insurance company. Therefore, you never receive a letter of denial. You should always receive one within a few weeks of "applying", otherwise, there is a strong possibility there was never an official denial by the insurance company.
· 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. Also make sure that the doctor submitted the correct information. Maybe they accidentally coded that you/your child was "in control" when in fact, that may not be accurate (more likely with ICD-9 coding than the new ICD-10). Perhaps they accidentally stated that there is hypoglycemic awareness, or didn't document the fact there were multiple low blood sugars a month prior to the appointment and they only downloaded/reviewed the past week's worth of blood sugar logs. Any of these little items could lead to a denial by the insurance, who is relying on the doctor first and foremost to make a determination of medical necessity.
· 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) (or vice-versa). 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 DME benefits for something they
now consider a pharmacy 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. It's stressful. 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 or that the A1c has to be within a certain zone. 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 due to XYZ, and a denial letter would have been sent. You could have appealed it and most likely gotten the device within 45 days. 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!! (Note: I see insurance companies retroactively cover, so always ask. It doesn't mean it is guaranteed, but if you don't ask, it is greater chance they will not retroactively cover/pay).
· It isn’t a true denial when you have large
co-pays/deductibles/co-insurance. 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% of the remaining $1,500) 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 find yourself in this predicament, please see my post on choosing insurance that best fits your needs.
· 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. The more
you make it sound like a mom wrote it instead of your attorney/doctor, the worse
off. Use words like “patient”; “post-prandial” (the after-meal
blood glucose); “caregivers” instead of parents/mom/dad/school nurse. Hypoglycemia, Hyperglycemia, Diabetic Ketoacidosis, etc etc. Don't assume that the doctor (or judge) reviewing the appeal knows what a CGM is/does or why it is so vital to the patient's well-being, so a short paragraph explaining the system is also helpful. Add any particular stories of severe blood sugar or any additional factors that may cause unexpected or delayed hypoglycemia, such as sports, swimming, etc. My appeals tend to end up between 10-15 pages long due to the amount of research data I include to back up my claims. Insurance companies need to know fiscally how not having this device could mean increased out of pocket due to emergency medical situations, backed by actual data. CGM's aren't cheap, but neither is an ER visit.
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. Remember, I am available for help!
[Updated March 2016: I am currently testing an appeal letter in pediatric Medicaid/Private plans for those offering NO coverage (ie: not based on medical necessity but rather due to not being included within coverage at all). Given the results, I may make this letter available to the general public. If you would like a copy in the meantime and have received the denial letter already, please contact me for a copy].
[Updated March 2016: I am currently testing an appeal letter in pediatric Medicaid/Private plans for those offering NO coverage (ie: not based on medical necessity but rather due to not being included within coverage at all). Given the results, I may make this letter available to the general public. If you would like a copy in the meantime and have received the denial letter already, please contact me for a copy].
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).
