How to Get Insurance Coverage for Diabetes Devices and Supplies
It took one full year for medical assistant Tammy Shankle, CMA, to persuade an insurance company to approve an insulin pump for a woman with type 2 diabetes. The woman, who was in her 50s, had been unable to stabilize her blood glucose levels with insulin injections during the two years following her diagnosis.
Letters, medical records, faxes, and back-and-forth phone calls with the insurance company lasted from April 2014 to April 2015, when the pump was finally approved. “When she got on the pump, she did beautifully,” says Shankle, who took charge of the appeals process on behalf of Tyree Morrison, CRNP, CDE, BC-ADM, a nurse practitioner and diabetes educator who ordered the woman’s pump.
Some people with diabetes are finding it increasingly difficult to get the supplies they need—including meters, medications, test strips, pumps, and continuous glucose monitors (CGMs)—covered by Medicare and private insurance. That’s especially true for people with type 2, and older adults in particular, who seek CGMs for better diabetes management. Medicare generally doesn’t consider CGMs to be medically necessary for people with type 2 diabetes and has denied coverage in most cases. In January, there was a small breakthrough: Medicare announced it would cover Dexcom’s G5 Mobile CGM as durable medical equipment, making it easier for recipients with all types of diabetes to get coverage.
Not surprisingly, appealing a claim’s rejection can be a time-consuming slog. Generally, to appeal a claim denied by an insurer, a provider (or an assistant such as Shankle) writes what’s called a letter of medical necessity, documenting with medical records why a particular product or device is necessary to improve a person’s blood glucose management and overall health.
Insurance claim rejections “happen all the time [for] people with type 1 and type 2 diabetes,” says Jessica Castle, MD, an assistant professor in the Department of Medicine at the Harold Schnitzer Diabetes Health Center at Oregon Health & Science University in Portland. “The rejection usually follows a request for a CGM or for newer, more-expensive meds.”
Even if you’re approved for a device, it may not be the one you prefer. If, for instance, your insurance covers a specific brand of meter but you prefer another meter for its ability to wirelessly transmit readings to your pump, you may be forced to pay out of pocket for your preferred meter and test strips. That’s a tricky decision for people with diabetes. “You could use another meter, but it wouldn’t transmit the glucose values directly,” Castle says. And inputting the numbers by hand ups the risk of human error, which could result in a wrong bolus dose of insulin.
Castle says people with diabetes who use CGMs often run into coverage problems when they switch insurers or enroll in Medicare at age 65. Typically, insurers approve coverage only if a person has at least one of the following, despite adhering to a dietitian’s advice and taking medication as directed:
- High blood glucose levels based on four checksa day and, in some cases, an A1C (a reflection of blood glucose levels over two to three months) that is above goal
- Frequent episodes of low blood glucose
- The inability to sense symptoms of low blood glucose (hypoglycemia unawareness)
Proving you meet the conditions above can be something of a catch-22 for people who are transferring insurers or trying for reapproval of a current CGM. “When you get approved for a drug or device, it’s not a lifetime approval. Typically it’s approved for a year,” Castle says. There’s a good chance that, during the course of that year, your blood glucose improved. That’s good for your health—and not so great for your case.
When an insurer checks your need based on those factors, it may say that your well-managed diabetes doesn’t necessitate the device. “It’s harder to prove that the device is medically necessary for the second plan because you’re already using it,” Castle says. “You have to look back at older records to prove you need the device—for example, when you were not using the device, you were having frequent low blood sugars, had a severe low blood sugar event requiring emergency medical assistance, or your A1C level was too high.”
Belinda Childs, APRN, MN, NP, CDE, BC-ADM, a clinical nurse specialist in Wichita, Kansas, says it can take two weeks to a month to get a response to an appeal. If it’s rejected, don’t quit. First appeals are usually read by nonmedical employees who toe the company line.
Usually, after a series of back-and-forth requests for documentation, the insurance company will set up a peer-to-peer meeting between your provider and an independent physician or diabetes educator, for example. “Those tend to be more successful [in gaining approval],” Shankle says.
Your provider may also ask you to write an appeal, stating in personal terms how the device has improved your quality of life. “Sometimes when you bring the [personal] story to the claim, it is enough to make the change,” says Joanne Rinker, MS, RD, CDE, LDN, senior director for community health improvement at Population Health Improvement Partners in Morrisville, North Carolina, who has helped people with diabetes win their appeals.
If you’re still struggling to get coverage for a CGM or other devices, meds, or supplies, don’t lose hope. “You just have to be willing to be persistent and look to the appeals process,” says Childs. “You are going to have to be willing to fight the battle to get it.”