Preparing Your Appeal:
- Work with an insurance liaison at the device company or your company to create your appeal packet. Many insurance companies have their appeal processes outlined on their websites, and you can use this information to outline your diabetes insurance appeal.
- Include your denial letter and any further communications from your insurance company.
- Find supporting medical studies and medical literature that outline the benefits of the device, treatment method, etc. Organizations like the JDRF, ADA, and even the medical device company itself may have a representative that can help you locate supporting documentation.
- Ask your doctor for a letter of medical necessity, stating that this device/treatment is necessary to improving your diabetes care.
- Send a letter of your own, stating clear and concise reasons for your appeal. Stick with more facts than emotions. Outline your health situation, you goals for treatment, and show how an approval will help avoid future diabetes complications.
During the course of your appeal process, keep a detailed timeline. Be sure to make notes on every phone call. Include the name of who you spoke with, the time and date of your call, and what was discussed. If you are denied again, there are usually several rounds of appeals you can go through. After you have exhausted all internal appeals (i.e. directly to the insurance company), you can usually appeal externally through your state by contacting your states board of health, or you can opt to take the case to federal court with the help of an attorney.
Theresa Garnero, APRN, BC-ADM, MSN, CDE, offers the following advice on managing insurance appeals: Do as much homework as possible when trying to find your durable medical equipment coverage and allow yourself plenty of time. Enlist the help of your endocrinologist and CDE staff when getting DME supplies authorized. You may be surprised to learn that your insurance carrier says it is covered, only to find out later that the item you need is a carve out (item with exceptions) that may be handled by a different part of your insurance company or another company entirely.
Also, keep notes of when, who, and what was discussed. Authorization for DME is rarely clear cut and a paper trail helps you to be organized in communicating your needs. The reality is that this can be a very frustrating venture when you are simply trying to equip yourself with the tools to improve your self-management. Be patient, get an advocate to help you be a squeaky wheel so you will maximize your efforts in making things happen!
Diabetes is expensive, and you owe it to your health to take advantage of what your policy has to offer. Keep at it, and if you have further questions, you can Ask an Expert!
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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...