Insurance — Navigating Denials
Dealing with diabetes is difficult enough. Add in navigating insurance and trying to get coverage for supplies or devices that you or your employer have seemingly paid for can be more than a headache—it can be an absolute nightmare. When it comes to insurance, there are a dozen variables to consider in terms of what plan you have and what is actually covered. If your doctor has prescribed it, isn’t that enough? In many cases, it isn’t and people are faced with denials for life-saving and life-improving equipment. Here is our run down if you’ve been denied a diabetes device or supply that your doctor has prescribed.
Establish whether or not you’ve actually been denied
Just because something hasn’t come in the mail, doesn’t necessarily mean you’ve been denied. If you’re denied, you’ll receive a letter in the mail detailing the following:
- What you’ve been denied
- Reason(s) detailing why you’ve been denied
- Your case number
- Your right to appeal (and where to send an appeal)
If you do not receive a letter like this, contact your insurance company and ask if your request has been processed. (It’s possible that it is still being processed and a decision regarding your request has not been made.)
If you’re denied—Wait for the letter (*see below)
If you’re not denied and have not received your supplies or device, it could be for the following reasons:
- Supplier issue: Sometimes a supplier says that the device or supplies aren’t covered because they aren’t contracted to supply that device or supplies. You’ll need to consider choosing a new supplier on your durable medical equipment (DME) list. Your insurance can provide you with a list of suppliers that are contracted to supply you with your equipment.
- Pharmacy issue: In some cases, your item isn’t listed under your DME list but instead under “Pharmacy Benefits.” (This is an issue of you’re looking in the “wrong department.”) Call your insurance company and talk to the pharmacy division and ask if your device or supplies are covered under these “Pharmacy Benefits.” NOTE: Dexcom has helpful downloadable pdfs that you can send to your insurance company for reimbursement disputes that fall under this category.
If you’re denied…
1. Look at the reason for denial
- If the reason doesn’t fit what is supported by your medical records, it could be the issue that your records are not accurate (filled out and/or filed properly with the insurance company).
- Ask your doctor to review these records and resubmit his or her request. (Sometimes it can be as simple as “hypoglycemia unawareness” wasn’t listed.)
- Ask your doctor to write a letter of “medical necessity” for the device or supplies. (This is important to do right away, because it will only strengthen your case.)
2. Request a “peer-to-peer” evaluation
- This is where your doctor talks to another medical professional (provided by the insurance company) about why the device or supplies are “medically necessary.”
- After the conversation, you’ll find out within 24 hours if you’re approved or not.
This is the beginning of a process that can take 30-60 days to hear back from your insurance company in the first round. Do NOT give up. It’s estimated that up to 80 percent of people who are denied medical equipment by insurance companies do not appeal, and insurance companies are banking on that.
- Examine the insurance company’s policy guidelines – If your company for example denies all continuous glucose monitors (CGMs), look at what research they provide that supports this. Sometimes it’s denied to a certain age group based on outdated research. (For example, “lack of effectiveness for patients under the age of 8.”) NOTE: Using age markers/restrictions is a good indication that their supporting research is outdated. This may fall under the Age Discrimination Act (1975), and you could be protected under this, so cite this in your appeal if it applies.
- Find research that supports your claim – Look at reputable sites such as the ADA and even on the websites of manufacturers of this equipment. (Omnipod for example offers excellent resources supporting the use of their equipment.) Google your question: “Do CGMs help adolescents in their diabetes management?” You’d be surprised what you can find just by looking online.
- Find organizations that support your claim – It is significant if the ADA supports your claim, for example, and you should cite this.
- Find out if there are federal or state laws that support your claim – For an example, some state laws say that an insurance company cannot deny a pump to someone with diabetes. Check HERE to see what your state laws are for diabetes care.
- Write your appeal – Now that you’ve done your research and have your references to support your claim, you’re ready to write the appeal.
How to write an appeal
1. Consider your tone – This means consider how you address whoever is reading this. Write not as the mother of someone who is exhausted and angry at having to go through this tedious process, for an example, but as an advocate who is not so emotionally invested. Telling the appeal reviewer how you cannot afford this on your own will most likely not help.
2. Use professional vocabulary – Try to write concisely and clearly, using the medical terminology you have found in your research when applicable. The more it sounds like it came from a lawyer or medical professional, the better chance you have of being taken seriously.
3. Organize your information – Break down your points into paragraphs and use bullet points to detail the supporting evidence you’ve accumulated. It will be easier to read and further support your claim in a professional format.
- Introduction – This should include your case number and detail: “x” item being denied for “x” patient and you’re appealing this decision.
- Detail denial – Give the reason that the company has given for the denial (this should have been detailed to you and can literally be copied word-for-word).
- Explain what the device/supplies do – Use laymen’s terms, assuming that the person reading this doesn’t have any experience with diabetes. For example, explain what a CGM does and how it assists in diabetes management.
- Provide research – This is everything you’ve gathered that supports your claim whether it be by state or federal law to recent medical studies
- Provide personal medical data – This could be your history of hypos or your A1C data. This information should support your claim of “medical necessity.”
- Explain applicable situations – If you need a pump for your toddler because dosing is hard to achieve with multiple daily injections (MDI), or if your high-level sports program frequently causes hypoglycemia hours after practice ends, this should be included. Just remember to correlate how the situations relate to medical necessity and take care to avoid “convenience” reasons.
- Detail complications – Discuss both long-term and short-term complications. If said device or equipment is not prescribed, these are the results based on “x” research.
- Conclusion – Drive home that for all of these listed reasons, “x” device is “medically necessary” for “x” patient. Conclude with “Thank you for your prompt and satisfactory resolution of this matter.”
After 30-60 days, you’ll either get approved or denied again. If you haven’t received an “external review” (a review by someone outside of the company), then keep appealing. Don’t give up. Remember, no one cares as much as you. You have to be your own advocate and relentless at that.
Source: Samantha Arceneaux, volunteer diabetes insurance advocate. For more information on pediatric insurance denials for CGMs or pumps, visit HERE.