New monitoring technologies come to market frequently, offering significant benefits such as the ability to read blood sugar levels continuously and provide information on blood sugar trends. While increasing numbers of people are using continuous glucose monitors (CGMs), many health plans have yet to make broad coverage decisions about them, and are waiting for the results of clinical trials–such as those now under way as part of JDRF’s Artificial Pancreas Project. In the meantime, some health plans grant individual or case-by-case coverage. JDRF encourages people using or planning to use CGM technologies to apply for coverage. Here are a few tips we have culled from insurance experts that can increase your odds of success:
- 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 CGM manufacturer’s customer service staff to see how they can help you.
- 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 with information about yourself and CGM and keep trying!
- Ask questions. Ask your insurance company if they have a “prior authorization” policy, an insurance policy that requires you to get approval before purchasing the device, and satisfy those requirements before asking for coverage. Also, find out what medical equipment supplier your insurance plan works with, and arrange to buy your device through them.
- Communicate the urgency for CGM coverage. To better your chances of receiving a positive coverage decision, you must communicate your urgent need 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, highlighting health problems and your need for a CGM
device, which may include:
a) Documented glycemic control problems (elevated HbA1c, frequent hypoglycemia,
hypoglycemia unawareness, overnight hypoglycemia)
b) Hospitalizations for hypoglycemia or diabetic ketoacidosis (DKA)
c) Emergency room visits
d) Glucagon administrations
e) Diabetes complications, whether early or advanced, such as kidney problems, nerve
damage, loss of feeling in feet, and eye problems
- Prescription for a CGM device from your doctor
- Description of your current care program (e.g., multiple daily injections or insulin pump, and
frequency of blood glucose self-monitoring) and a record of adherence to your care plan from you
- Certification that your physician or other care provider (e.g., Certified Diabetes Educator) will be supervising your treatment plan with the addition of a CGM device
- File for case-by-case coverage. Send all the above materials to your insurance company.
- Know your insurance company’s appeals process. Since CGMs are not widely covered by insurers, it is likely that you will be initially denied coverage and will need to appeal the decision.
- Submit your appeal. Send the appeal to your insurance plan with the materials outlined above in Step 4 within the time frame outlined by your insurer.
- Appeal, appeal, and appeal. The more you appeal each denial, the more you are helping put pressure on insurance companies and making them aware of the demand for coverage of these devices. Don’t give up!
- Please tell us your story! 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.
- Sign up to be a JDRF advocate. You can join with others affected by type 1 to advocate for health coverage for CGMs and funds for diabetes research. Click here to sign up to be an advocate.
Click here to reach a JDRF volunteer to answer your questions about continuous glucose monitors, the artificial pancreas, or any questions about life with diabetes. To learn more about CGMs and the artificial pancreas, click here.