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Denied again - Update - the letter

I received the latest letter of denial from my insurance company.

Here’s what the letter says:
“This appeal was reviewed by an independent external consultant, Board Certified in Internal Medicine with a Sub Specialty Certificate in Endocrinology Diabetes & Metabolism….
… Although the patient has met the criteria of being on on intensified insulin therapy program, and has a hemoglobin A1C of greater than 7%, there is no documentation to support low endogenous levels in the member. Her C-peptide level is within normal limits, which is not unexpected, since cystic fibrosis is associated with impaired glucose tolerance rather than primarily decreased insulin production.”

Now, I am quite confused. I thought that CFRD was caused because of decreased insulin production because the pancreas is damaged and not able to produce enough insulin to keep blood glucose at safe levels? Could their “expert” be wrong?!

(-sarcastic comment warning-) I am wondering if the independent reviewer believes that I am overweight (5′5″ 107lbs) and should control his assumption of “Type 2″ diabetes by dieting. OH PLEASE!!

Note: I do NOT have Type 1 OR Type 2 diabetes. I have CF Related Diabetes. It is a whole different bear all it’s own.

Here is the denial for the continuous glucose monitor:

“The continuous glucose monitor was denied again because it “is still considered experimental and investigational, with the therapeutic benefit yet to be proven in large-scale long-term studies. … continuous glucose monitoring system is considered experimental / investigational / unproven and is not in accordance with generally accepted standards of medical practice at he the present time, it would not be considered medically necessary.”

Does any one have any comments or suggestions about how to refute this claim??

I have found out that my insurance, GreatWest Healthcare, is notorious for denying coverage for insulin pumps. Unfortunately I can not switch my insurance policy, as it is the only one offered by my employer.

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This entry was written by Salty and posted on February 15, 2008 and filed under Challenges, Cystic Fibrosis, Cystic Fibrosis Related Diabetes, diabetes, insulin pump, insurance.
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4 Comments so far (Add 1 more)

  1. Hi bkj1981,
    Thanks for the advice.
    I will ask my doc about those alternative tests, although it is in Great-West’s policy that I have to have a low C-Peptide level, or show autoantibodies (which is only a case for Type 1 diabetes, not CFRD) to receive insulin pump coverage.

    We are about to begin the last and final appeal, which may have to take a trip to Columbus Ohio to see another specialist who is familiar with CFRD to get a second opinion.

    1. aspen on April 3rd, 2008 at 4:48 pm

  2. I am one of those “professionals” that works on getting insulin pumps for people with diabetes at a large company. I have yet to come across any particular patient that had, to my knowledge, CF related Diabetes. In my experience it really depends on the type of insurance that you carry. Most insurances are not covering the Continuous Glucose Monitoring System(CGMS) for the same reason as the denail letter you have received. We have found with some insurances that if you and your doctor get involved in the appeal process, sometimes called a pier to pier review, the claim can be overturned/approved but it will take some work on both parts. It can be a lengthy and sometimes difficult process but if resulting in an approval can be very beneficial for you.

    Another thing with the lab work that is drawn that in instances that the C-Peptide levels are within normal range is to try the Alternate labs that should be acceptable. Those are; Insulin Autoantibody, Islet Cell or Beta cell, and a Gluctamic Acid Decarboxylase Autoantibody(GAD AB) test. You can google each of these to get the definition of the purpose for the test.

    I hope this helps and if you would like you can email me directly and I can try and help you more.

    2. bkj1981 on March 20th, 2008 at 4:53 pm

  3. When I needed approval, I got the pump company to apply for it. They make quite a bit of money when a pump is approved, so they work quite hard to ensure that it is. If your insurance never approves pumps for the less common forms of diabetes, it may not work, but it might and it would save some stress for you! There are also some pretty good payment plans if it turns out that a pump is something you’d be willing to pay for out of pocket. I would really recommend contacting a pump company… and probably the biggest in the USA, Minimed.

    I’m sorry to hear about this. Extra stress is the LAST thing that a person struggling with chronic illness needs. I hope that you find a resolution that works well for you, and let me know if there’s any way that I can help you out!

    3. in search of balance on February 18th, 2008 at 11:47 am

  4. My 2 cents:

    If I were you, I’d schedule a clinic appointment and bring your letters with you (or just call to see if you can see your CF doctor during some kind of hospital office hours) and ask if it would be possible to get a letter arguing the conclusions of the “expert” who might be operating on false assumptions.

    The “expert” is likely only book educated from old studies on the effects CF has on the endocrine system. My doctor said there is one major informational or medical breakthrough every month that I’d bet passes by every medical person outside the CF/respiratory arena.

    There simply aren’t enough of us to warrant brush-up training on our issues, and there sure the heck aren’t enough of us with CFRD for all the specialists to know about CFRD. I didn’t know about it until my wife found your blog, so it wouldn’t surprise me if dozens of CF specialists aren’t recognizing it yet. I knew diabetes is a risk based on our high simple carb diets, but for it to be anything other than Type 2 diabetes was news to me.

    If this doesn’t work, in all seriousness, you might have to look for an employer that offers another health insurance. I went 3 years using a self-insured policy with Aetna to get the coverage I needed, despite the crippling premiums. It was taking close to 30% of my monthly salary, but it was what had to be done to get the meds I needed.

    Still pulling for you from Florida.

    4. Jesse Petersen on February 18th, 2008 at 6:50 am

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