The Battle for Continuous Glucose Monitoring Insurance Coverage
Recurring Medicare denials a mystery
By Joe Guarneri
dLife Staff Writer
David Terleckas, a 57-year-old resident of Pennsylvania, has had type 1 diabetes for nearly 47 years. On top of this, he is hypoglycemic unaware, making coping with his diabetes that much more of a challenge. In the past, David had always used a continuous glucose monitor to combat this condition and avoid having to constantly check his blood glucose level – until recently. Being forced to retire early due to diabetes, he is now covered under Medicare, who is currently denying coverage of CGMs and other related diabetes supplies. With the severe risks that diabetes poses and the convenience CGMs bring to those who attempt to combat it daily, why is continuous glucose monitoring insurance coverage by Medicare so difficult to obtain?
There are close to 100,000 hypoglycemia-related Emergency Room visits a year, with 29% resulting in hospitalization. If you add the possibility of hypoglycemic unawareness in some of those cases, the severity of the situation rises and the increased chance for self-injury and harm to others becomes even more striking. David emphasized the fact that when a person's blood sugar reaches a harmful low, it becomes hard for them to control their actions. "You can't seem to get this across to Medicare," David said.
In an attempt to get through to Medicare, David (pictured left), along with his wife, a close neighbor, and his doctor, appeared before a judge in order to try to sway Medicare toward covering his CGM. "The case ended up being in our favor, but when I reordered the CGM, it was denied again." So despite all of this, David would have to appeal every time he ordered supplies for his CGM, something that anyone with diabetes knows occurs very frequently. Along with the hearing, David even spoke to representatives in the Surgeon General's office, as well as Medicare representatives in Washington, D.C.
In response to this issue in general, Claudia Graham, the Vice President of Global Access at Dexcom, has been working among a coalition of patient advocates, clinical societies, and companies "focused on the goal of providing access to CGM for Medicare beneficiaries, as it is nearly universally available in the commercial market." She explains that in order for Medicare to cover a given product, it must be assigned to a benefit category. "This is exactly where the hang up is," Claudia says. "Medicare is saying that CGM devices, according to their FDA label, must rely on self monitoring of blood glucose prior to making dosage/treatment decisions, and because of this Medicare will not assign a ‘benefit category'." Claudia and the rest of those involved are trying to voice to Medicare the value of CGMs to those who need them. She feels that because the device has allowed so many people to avoid hypoglycemic events, the fact that those same people are being denied coverage on it upon turning 65 is unfathomable. When asked why continuous glucose monitoring insurance coverage is being denied, Medicare replied that denial is purely based on the medical information submitted on one's claim.
While people like David and Claudia continue to express the importance of CGM to Medicare, it is important to know what to do if you find yourself in a similar situation. David advises others in his position to pursue it – go through the necessary appeals, and research to find people who can help in the process. He also stresses the importance of communicating with your doctor, as they can help you find other options, as well as aid you in communicating with Medicare and other organizations. By taking part in all of this, you can not only help yourself, but also help the rest of those making the effort to get through to Medicare on this serious issue.
Avocado and Grapefruit Salad Low-Fat Butter Spread Grecian White Omelet Creamy Instant Pumpkin Mousse Hoisin Spring Rolls Sun-Dried Tomato Hummus Whole Wheat Waffles Mini Spinach Calzones Low Carb, Low Fat Creamy Dressing Curried Apricot Vegetable Medley
As I mentioned in an earlier post, one of the benefits that made it cost-effective for me to go with the real healthcare (HSA) plan rather than the phony (HRA) plan is that my company is now covering "preventative" medicines at $0 copay. The formulary for these, as stated by CVS/Caremark (my pharmacy benefits provider), covers all test strips, lancets, and control solutions. I dutifully get my doctor to write up prescriptions for all of my testing needs, submit...