CGM Denied… Again

The Dexcom was denied once again after an urgent appeal to United Healthcare.

Ugh. This is frustrating. The letter stated I was out of appeals and my next step would be to get a third party involved. The reason: The FDA has only approved the CGM for Type 1 Diabetes. I’m just one mom, there’s no way I can get the FDA to help us, right?

I know insurance companies are all about the bottom line. I get that. I understand that. I really do but this morning when Jackson’s sugar dropped into the 60s without warning, we would have known he was declining if he had this machine.

To the doctor who gets to make these critical decisions: To you he may just be another “claim”, to me, he is my whole world. Please do the right thing. 

Insurance Denies – CGM

Jackson’s endocrinologist requested that he receive a Dexcom G5 Continuous Glucose Monitor. He warned it would likely be denied by the insurance company.

I seriously thought, there’s no way. How could the insurance company deny a device that could literally save his life? I have talked to the insurance company several times since Jackson’s birth and truth be told, they’ve been incredibly pleasant to talk to. No issues whatsoever.

When the insurance company denied the claim, even after prior authorization, I was a little shocked. I know, I had been warned but they had been so easy to work with, I expected more from them. I decided to call and talk to them. Surely, if they understood Hyperinsulinism, there’s no way they would deny it, right? WRONG

Their reason? “BECAUSE PATIENT DOES NOT HAVE TYPE 1 DIABETES, THIS DEVICE IS NOT MEDICALLY NECESSARY”. Ok, deep breaths. So I go into a long drawn out explanation of HI, the risks and the need for continuing to monitor blood glucose levels. I try to stick with simple facts:

  • He doesn’t have diabetes, but has a disease that affects his glucose level.
  • He is severely hypoglycemic.
  • If his blood glucose level (BGL) drops and I don’t catch it, he could suffer brain damage or worse.
  • He’s six months old, he can’t tell me if he doesn’t feel good. This machine will communicate for him.
  • This machine isn’t just necessary for diabetics, it’s necessary for all people who have to monitor BGL 24-7.

That wasn’t enough justification. So in a desperate plea, I submitted an appeal. Telling them everything I knew about the disease and basically begged that they’d re-consider. Julie with Congenital Hyperinsulinism International also wrote a letter encouraging them to reconsider. Asked that they look at the facts. The truth is, if he suffers brain damage, the medical expenses will far exceed that than the coverage of this device. It’s the right thing for them to do and could save them money in the long run.

They said they’d make a determination on the appeal in 30 days. So… we wait.