Artificial Pancreas Project

Steps For Obtaining Case-By-Case Coverage For Continuous Glucose Monitors (CGMs)

As a result of the new evidence from the JDRF CGM trial, many health plans are increasing coverage for CGM. If your plan doesn't have a formal coverage policy for CGM yet, you may still be able to get coverage for yourself by applying for "case-by-case" coverage. Here are a few tips we have obtained from insurance experts that can increase your odds of success.

  1. Determine your plan's coverage policy for CGM. Increasingly, health plans have issued formal decisions on whether or not CGM is covered. Before proceeding with the case-by-case coverage process outlined below, it is important to verify what your plan's official policy on CGM currently is. JDRF has posted information about CGM Coverage at Select Health Plans, as well as instructions regarding how to search for policies at other plans. If your plan has a policy which covers CGM, proceed through the normal process to obtain a CGM. If your plan has a policy which does not cover CGM or does not have a formal policy on CGM, follow the steps outlined below. If you are a Medicare beneficiary, see these tips for more information.
  2. 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 and to keep trying!
  3. 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 continuous glucose monitor (CGM) manufacturer's customer service staff to see how they can help you. In addition, make sure to include in the paperwork to your health plan the HCPCS codes for CGM devices, which help the health plan to identify and process payments for the technology. The codes for CGM are A9276 for the sensor, A9277 for the transmitter, and A9278 for the receiver.
  4. Ask questions. Ask your insurance company if they have a prior authorization policy, an insurance policy that you must have approval before purchasing the device, and satisfy those requirements before asking for coverage.
  5. Communicate the urgency for continuous glucose monitor (CGM) coverage. To better your chances of receiving a positive coverage decision, you must communicate urgency 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 which highlights health problems and your need for continuous glucose monitor (CGM), which may include:
      • Documented glycemic control problems (elevated HbA1c, frequents hypoglycemia, hypoglycemia unawareness, overnight hypoglycemia)
      • Hospitalizations for hypoglycemia or DKA
      • Emergency room visits
      • Glucagon administrations
      • Diabetes complications, whether early or advanced, such as kidney problems, nerve damage, loss of feeling in feet, and eye problems
    • Prescription for continuous glucose monitor (CGM) and sensors from your doctor
    • Description of your current care plan (e.g., multiple daily injections or insulin pump, and frequency of self monitoring of blood glucose) and a record of adherence to your care plan from you physician
    • Certification that your physician or other provider (e.g., Certified Diabetes Educator) will be supervising your care and maintaining your treatment plan with the addition of continuous glucose monitor (CGM)
    • Cite current clinical studies which show continuous glucose monitors improve glycemic control. They include:
      • Results from a recent clinical trial funded by JDRF showed that people with type 1 diabetes using CGM regularly experienced significantly better glucose control.
      • A paper from the JDRF funded study of the second six month period and the results show that the initial benefit of significantly improved glycemic control was sustained and that consistent CGM use continued through the entire 12 month study period.
      • A study that expands upon the New England Journal of Medicine paper and shows that the primary driver for the A1c reduction was sensor use and that irrespective of age, patients who consistently used their CGM saw significant reductions in their A1c.
      • A study of another cohort of the JDRF funded trial that showed that CGM use also benefits those who already have their diabetes under good control.
      • One study found people using CGM spent 26 percent more time each day in their target glucose range, and significantly less time with hyper and hypoglycemia.
      • Another trial showed that diabetes patients using CGM had a statistically significant drop in HbA1c compared with a control group, and they spent significantly less time below 70 mg/dl and above 190 mg/dl.
      • An observational study of people using CGM showed a significant reduction in HbA1c in people using CGM.
      • A fourth study found patients at all A1c levels spent increased time in target glucose ranges when using CGM.
    • Cite the Aetna, CIGNA, Humana, United, and Wellpoint/Anthem policies covering CGM.
  6. Know your insurance company's appeals process. Since CGM is not covered by all insurers, you may be initially denied coverage and you will need to appeal the decision.
  7. Submit your appeal. Send the appeal to your insurance plan with the materials outlined above in Step 4 within the timeframe outlined by your insurer.
  8. Appeal, appeal, and appeal. The more you appeal each denial, the more you are helping put pressure on insurance companies and make them aware of the demand for coverage of these devices. Don't give up!
  9. Help us expand plan coverage policies. JDRF is working with health plans to provide coverage for CGMs, but we need your help! Plans need to hear directly from their beneficiaries about this revolutionary technology. The first step is to tell us your health insurance provider.

 

Links