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[IP] Re: Medicare Coverage for CGMS



Joanne,
 
I live in New York and have been denied CGM coverage by my Medicare Advantage
plan.  The reason for the denial was that the DME contractor for NY and many
other states (NHIC) published a policy article (A33614) that denies coverage
because CGM is precautionary.
 
I have been denied through three levels of appeal.  The administrative law
judge (ALJ) issued an UNFAVORABLE ruling in my Level 3 appeal based on the
NHIC policy article.
 
I would suggest that you order a CGM system and ask the supplier to file a
claim on your behalf.  Make sure your MD provides a letter of medical
necessity stating the reasons why you need CGM.  If you are denied, then file
an appeal for reconsideration with your health care plan.  There are up to
five levels of appeal for Medicare plan denials.
 
If you have limited income, you may be able to get some legal help.  The
appeal process is cumbersome, but unless many of us go through the process,
Medicare will not change the CGM policy.
 
I have prepared an appeal (Level 4) for the Medicare Appeals Council (MAC) in
Washington, DC.  The MAC will review the  ALJ decision (Level 3).   It has
been a long process, but I have learned a lot and would encourage anybody that
is denied coverage to appeal.  The more appeals that are filed, the better
chance CGM users have in obtaining coverage.
 
If you want to read the Medicare CGM policy article (A33614) go to the
following link:
 
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?a
rticleId=33614&ver=15&ContrId=137&ContrVer=1&DocID=A33614&bc=IAAAAAgAAAAA&
 
Jerry Smith
Rochester. NY   
 
 
Date: Thu, 5 May 2011 11:21:09 -0700
From: "R & J Milo" <email @ redacted>
Subject: Has anyone in CA been successful getting CGMS covered by Medicare?

I've been denied by Medicare for CGMS coverage in CA.  Before I start a
claim, I was wondering if anyone has successfully gotten CGMS coverage in
the state of California.  You can answer this privately.
 
Many thanks . joanne (dx'd 1965, Cozmo/Omnipod, Dexcom/Navigator)
.
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