There are two possible approaches for reimbursement. Patients can submit claims themselves for reimbursement without prior authorization. They will need a letter of medical necessity from the physician, along with individual invoices showing payments. It's a good idea to submit the invoice for the starter kit separately from the sensors, to improve the chances of staying “under the radar” in terms of any monetary caps (typically $500–$600) on device coverage that the insurer may have, she advised.
The other approach is for the physician's office to submit the request for prior authorization. Be prepared to write several letters. The initial letter of medical necessity should be kept relatively short. Include the patient's name, date of birth, insurance identification number, the medical necessity for the device, and information about the device, including utility, cost, and potential cost savings.
If the initial request is denied, the first letter of appeal—sent to a specific appeals person along with the case number of the denial—should go further in making the case. Provide information about hospitalizations for hypoglycemia or ketoacidosis, emergency visits, glucagon administration, lost time/injuries at work, previous complications related to low or high blood sugar, and any physician notes regarding labs, procedures, current care plan, and frequency of testing. It's also a good idea to provide journal abstracts highlighting the patient's specific needs. But don't send the entire article, because insurers will often point to the one sentence at the end saying that “more research is needed,” Ms. Halford advised.
The third letter goes to the company's medical director. Include all the previous identifying information, but it's not necessary at this point to include lab work and medical information, because there will already be a file on the patient. Here, the goal is to address the patient's “right for appropriate and adequate medical care” and the insurer's “obligation” to meet those rights. Be sure to address any previous argument the company made against coverage.
It may also help to request a letter from the manufacturer's managed care director, who can review the clinical merits of CGM, clarify any misunderstandings regarding the therapy, address technology criteria set out by individual insurance companies and how CGM meets them, and assist with developing medical policy for CGM.
Although there are as yet no long-term outcomes data on CGM, there is certainly plenty of literature on the relationship between good blood glucose control and prevention of complications, including the landmark Diabetes Control and Complications Trial. Articles on the cost savings to insurance companies when hemoglobin A1c levels are improved may also help. “Provide the insurance companies with a comprehensive list of reference materials,” Ms. Halford recommended.
It might help to “piggyback” the CGM with other covered technologies, such as the insulin pump or the fingerstick method for self-monitoring of blood glucose. In all, 19 states (Alaska, Colorado, Connecticut, Florida, Louisiana, Maryland, Minnesota, Mississippi, Missouri, Nevada, New Hampshire, New Mexico, North Carolina, Oregon, South Carolina, Vermont, Virginia, Wisconsin, and Wyoming) and the District of Columbia have now mandated coverage for self-monitoring. One major insurer (CareFirst BlueCross BlueShield) has begun covering CGM technologies in Maryland, Virginia, and the District of Columbia because of its interpretation of Maryland's statute requiring coverage of all “glucose monitoring technologies and supplies.”
“If you're fortunate to live in one of those states, you want to check and see if there's a little opening you can wiggle your toe into and pry the door open,” she said.
Another avenue to try is calling the state health insurance commission to discuss why the patient is being billed for out-of-network costs when “in-network” relationships don't exist because they have not yet been negotiated between manufacturers and distributors.
And one more possibility: Use the Americans with Disabilities Act for patients who risk losing their jobs secondary to poor blood glucose control. Insurance companies can't be forced to cover CGM, but if they cover things like hearing aids and special glasses, then they must “equitably” provide coverage for CGM. At least that argument is worth a try, Ms. Halford said.
