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Re: [IP] CGMS Denial Info



Would you mind me asking which insurance company those criteria are for?


--- On Fri, 7/4/08, DAVID HANCOCK <email @ redacted> wrote:
From: DAVID HANCOCK <email @ redacted>
Subject: [IP] CGMS Denial Info
To: email @ redacted
Date: Friday, July 4, 2008, 9:00 AM

As I have posted here before I work for an insurance company. Our  
criteria for "qualifying" for CGMS is

1. Type 1 DM
2. Test BS at least 4 times a day
3. Recurrent "severe" hypoglycemia of less than 50 mg/dl
4. Frequent BS above 150 mg/dl
5."Poor control despite compliance with frequent changes in the  
medical regimen."
6. Three or more injections a day or use of an insulin pump.

I don't know how the Appeals side of things work and how often  
decisions get overturned, but I do know the initial decisions are  
very much by the book--you either meet the criteria or you don't.  
Everyone has to be treated the same so adherence to contract and  
clinical and coverage guidelines is very tight.  When I do denial  
letters I always spell this out so when the Dr calls back to do the  
peer to peer they know exactly what we're looking for.

I don't agree with the guideline on this one. I think it's just as  
dangerous to have high blood sugars all the time as to have those low  
ones which one must have to qualify but it is what it is. I do think  
that eventually the guidelines will not demand the lows be present  
but that's just my opinion.

FYI...

Kelly
.
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