ST. LOUIS — Obtaining insurance coverage for continuous glucose monitoring may be something of a battle right now, but in many cases it's a winnable one, Jean R. Halford, R.D., said at the annual meeting of the American Association of Diabetes Educators.
The continuous glucose monitoring (CGM) device that provides data directly to patients is very recent technology. Medtronic Inc.'s Guardian system was approved in limited release by the Food and Drug Administration in July 2005. In early 2006, two CGM systems—Medtronic's integrated system (the MiniMed Paradigm REAL-Time Insulin Pump and Continuous Glucose Monitoring System) and DexCom Inc.'s STS system—were approved. In March 2007, Medtronic's second-generation Paradigm RT system with the MiniLink transmitter was licensed, and in May 2007, DexCom received approval for its new 7-day sensor (the Seven System). Abbott Laboratories' investigational Freestyle Navigator CGM system is expected to receive approval very soon.
As with all new expensive technology, insurers are not rushing to cover CGM. Medtronic's Guardian costs $1,399, whereas the Paradigm is $999 minus the cost of the pump, which is typically covered. The 3-day sensors cost $35 each. The Seven System is $800, plus $240 for a box of four 7-day sensors.
Because of these high costs, many health care professionals are holding back on recommending CGM to patients because they know it probably won't be covered. “I believe it is our role as educators to make our patients aware of all the devices and technologies that are out there. … We shouldn't preclude who we talk to based on whether they have insurance coverage,” said Ms. Halford, a licensed dietician and certified diabetes educator at the Rocky Mountain Diabetes and Osteoporosis Center, Idaho Falls, Idaho. The center, which is the largest diabetes practice in the state, currently has 175 patients using continuous glucose monitoring.
Reimbursement may become easier in 2008, when the Centers for Medicare and Medicaid Services is expected to issue new Healthcare Common Procedural Coding System level II codes specifically for CGM. But in the meantime, the “junk codes” E1399 and A9999 (miscellaneous durable medical equipment) might work. Alternatively, Ms. Halford suggested, it's worth trying the CGM code S1030, which was developed for the previous device, the GlucoWatch. That device is no longer on the market, but the code's description— “continuous noninvasive glucose monitoring device, purchase”—doesn't specify any brand.
There are also two CPT codes (95250 and 95251) that were initially implemented for use with the Medtronic Continuous Glucose Monitoring System, which is worn by patients for 3 days, after which the physician downloads the glucose values. That device, first approved in 1999, does not provide results directly to patients. With the new systems, the same CPT codes can be used for CGM initiation and education, and for physician interpretation and report, respectively. Make sure those codes are in your contract, Ms. Halford advised.
But of course reimbursement isn't a guarantee even with a code, and—even if a patient's insurance does approve CGM—there is likely to be a huge out-of-pocket deductible for what is thus far a uniformly “out of network” expense. Until long-term data are available, insurance companies are likely to view CGM as investigational. “They think of it as a fancy traditional point-in-time glucose monitor. … They cannot comprehend the utilization for better control and peace of mind for the patient,” she noted.
So educating insurers is part of Ms. Halford's “coordinated battle plan”: First, identify the key individuals at each CGM manufacturer and develop a working relationship with them. Once they recognize that you are a “champion” of the technology, they will provide needed resources. Next, identify and meet the insurance company's case managers and develop a relationship with them. These individuals can be extremely helpful, Ms. Halford noted, as they are often in close contact with the company's medical director.
If possible, try to schedule a meeting with the insurance company's medical director and case manager, as well as the CGM manufacturers' managed care directors. “If we're persistent, we can make these contacts. You just have to want to make it happen,” she remarked.
Initially at least, it makes sense to go after the “obvious” patients who would benefit from CGM, such as women with type 1 diabetes who are pregnant or planning a pregnancy, patients with gastroparesis, those on dialysis who are unable to get on the kidney transplant list unless their glucose control improves, or those with hypoglycemic unawareness, which is the one condition that the insurance companies “are really tuned into,” she noted.
It's important to submit every prior authorization every time, so that insurance companies can see that there is a demand for continuous monitoring. With each letter, find out exactly what information they want and provide it. Create a file for each insurance company, including fax and telephone numbers, and key contacts.