by Joanne Milo
16 July 2014
Medicare (except in Advantage HMO plans) does not cover any CGMS. There are codes for sensors, receivers and transmitters! But their ruling, in 2008 (when they just came on the market), deemed them “precautionary.”
How is “precautionary” defined? Who knows … it’s certainly not a term one can find in all the Medicare formulary data. So this becomes circular logic. No one knows what “precautionary” means but because Medicare cries, “PRECAUTIONARY,” CGM is NOT COVERED.
I just couldn’t believe that I couldn’t somehow convince Medicare that CGM was not only critical to my life and my long term well-being, it was also cost-effective over multiple daily test strips. I threw my heart and soul as well as hours of research and letters from my doctors.
First Level Appeal: DENIED because CGM is PRECAUTIONARY.
Second Level Appeal: DENIED because CGM is PRECAUTIONARY.
Third Level Appeal and phone hearing with Administrative Law Judge, whose 50 year-old son has
diabetes (probably Type 2) and does just fine testing 2-3 times/day. DENIED because CGM is PRECAUTIONARY. The ALJ even wrote that I proved medical necessity and I proved cost efficiency! But still denied!
Fourth Level Appeal: DENIED because CGM is PRECAUTIONARY.
My next step, if I had the time and money, was to sue Medicare. Don’t have the money or time. Asked for support from a CGM company … again DENIED.
CGM has been available to the diabetes market since 2008 … and been improved and revised. According to Dr. Steve Edelman, UCSD and a T1, the best strategy for avoiding sudden death in bed is to use a CGM. This is an essential medical device in the treatment of Type 1 diabetes!
Why is it taking so long? Why isn’t Medicare listening and revising their policy? What about Congress? What about ADA and JDRF? AARP? Insulin pump and CGM companies?
Well, there is a bill in Congress that I have been tracking: HR 3710: Medicare CGM Coverage Act. It was introduced December 11, 2013. You can read about this bill at: http://tinyurl.com/n2taouk
But the bottom line, the prognosis:
1% chance of getting past committee
0% chance of being enacted
REALLY?????? WHAT DOES IT TAKE???
A friend who serves on the Board of the local JDRF chapter and whose wife is a T1, approaching age 65, has taken it on as his mission to effect a change in the Medicare policy regarding CGM. His approach is to change the definition of Durable Medical Devices as defined by CMMS. But he is finding it difficult to get a focused effort among all the organizations. Insulet is focused on coverage for Omnipod. JDRF is focused the artificial pancreas, AARP cares about Medicare cuts, ADA is not very involved. He says that the best bet is to petition Congress because all they listen to is money and votes. I understand that Medtronic and Dexcom have approached Medicare but thus far, have been totally ineffective.
I don’t have the answer … but I do have plenty of frustration. I would gladly participate in a concerted campaign to Congress but feel discouraged that our voices don’t matter enough to them. I absolutely welcome any feedback and suggestions on how to really make Medicare see the light. And I thank you for reading along.