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[IP] Re: Medicare Advantage (CGM)



Hi Judi in Michigan,
 
I was very interested in the comments about your Medicare Advantage plan.  Do
you know if local Medicare policy in Michigan requires CGM coverage?  My plan,
in Rochester, NY, denies CGM coverage because it is precautionary.  Medical
necessity is not taken into consideration!  I am currently at Level 4
(Medicare Appeals Council) in appealing my plan's denial of coverage.
 
It would help my appeal if I knew the name of your plan.  There is no national
determination of coverage for CGM by Medicare.  Local Coverage Determination
(LCD) is determined by Medicare DME contractors, NHIC for new York and several
other states.
 
Thank you for any information you can provide.
 
Jerry Smith
Rochester, NY 
 
 
Date: Tue, 03 May 2011 15:36:49 -0400
From: Jath622 <email @ redacted>
Subject: Re: : [IP] Medicare billing re insulin

I am also in a Medicare Advantage Plan, although a different plan than Diane
is
on in MI. I do have to pay a co-pay for my insulin. When I went into this
plan,
I inquired of the state insurance department, Medicare, and my plan I went
into.
I was advised the same by all three. When you are in a Medicare Advantage
Plan,
the insulin falls under the drug portion of your plan. This is only if you
are
in a managed care plan.

However there are other advantages to this type of plan. (1) I do not have to
see an endo every 3 months like the Medicare rules say. I can follow the
recommendations of my endo, which is every 6 months for the level of care that
I
require based on my needs. (2) All my pump supplies are paid for 100%. (3) I
am
given the test strips that are prescribed for me without any hassels and that
is
12 tests a day. I do not have to submit any paperwork to obtain these strips.
(4) I can get 1 box of Dex sensors (with no cost to me) per month. When my
Nav
broke, my plan gave me a Dex by my endo submitting the request forms. He
submitted the forms on a Wed and the approval was given on Thurs.

You need to weigh the pros and cons of what you need and what is available to
you in your state. For me, these were the best options. Paying a co-pay, for
me,
was not the biggest expense.

Judi in MI
.
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