Walking a Fine Line

For the last two months or so, Little Brother has benefited from some wonderful technology that helps with his diabetes care.

dexcom g4

This continuous glucose monitor checks his blood sugar every 5 minutes, allowing us to get ahead of highs or lows–and those lows are happening with greater frequency now that the weather is fine and he’s spending hours on end in the pool. In addition, the routines and schedules around schoolday mealtimes are not in place in the summer, so we can use all the help we can get.

But I got a phone call yesterday from the manufacturer of this device, informing me that our insurance won’t cover it because the diabetes medical provider used a certain diagnosis code. If a different code were used, this would be a no-brainer. Our provider used a code that means “diabetes with no complications.” If they had used the code that means “diabetes, uncontrolled” we could have the CGM.

So basically we’re too good at caring for our child to qualify for the technology that helps us care for our child.

Little Brother has a picture-perfect A1C (an average blood sugar over 3 months). For 2 of those last 3 months we have had the CGM to help us keep him there. But in the last few weeks, his sugar has been on a roller coaster, what with swimming and backyard soccer and sleeping late and eating at friends’ homes where Guess The Carbs is a spectator sport. In the past 2 weeks he’s had several scary lows, including last night when he “pinned” that meter at 40 for more than 10 minutes (a blood test, at one point, showed his glucose level at 37).

If that’s not “uncontrolled,” I don’t know what is.

We need all the help we can get, and his provider and the insurance company are making it really difficult for us to do that without incurring crazy out-of-pocket expenses.

13 thoughts on “Walking a Fine Line

  1. Barb, I feel your pain. It seems that I am always fighting with Tricare over something. The bottom line is insurance companies, especially HMO plans, make more money the less care they pay for so it always seems like an uphill battle to get services covered. Since you know the appropriate code, will your primary provider resubmit the request using the correct code? Another thought is to ask the manufacturer or perhaps one of the specialists Little Brother saw at CHOP if there are any clinical trials for the device going on in your area. If Little Brother qualifies for a study, the device is covered. You may have to make a few extra office visits for study data. Finally, check with a diabetic supply company and see if there are any similar options to this device that are less expensive. Praying it all works out!

    • IDK if we can get this done through our primary. But the endocrine team refuses to use the required code; I guess in their minds he doesn’t “qualify” for that diagnosis. They’re not sitting in my seat, where I’m treating a low of 37 on a Thursday evening–or my husband’s, where he’s waking up a few times a night. I think if we get nowhere fast with CHOP, I’ll ask our contact at the manufacturer if our primary can submit the form for us. Thanks for that idea, and for the prayers.

  2. It figures…take good care of your health, pay more. We just went through this when we found out unexpectedly that the insurance covered barely pennies of a routine tetanus shot. But of course, if one of us actually GOT something scary like tetanus, they’d cover it. Makes you wonder….the talk is always prevention! prevention! and then they won’t cover it unless you’re already super sick. Good luck with your son. Thinking of you!

  3. Can you schedule an appointment with the endocrinologist to discuss the challenges you are experiencing now that school is out? Usually the doctor doesn’t have a problem with you getting what you need and is willing to do what is necessary to get the insurance company to pay. I’ve gone through the same thing trying to get “the code right.” I’m going through it right now to get home testing for my INR.

    • The endo nurse practitioner WILL NOT change the code. Period. But she would “write a letter to help us appeal.” That could take forever. I am taking LB to his primary today with the form to be signed and a 6-week printout of his glucose monitor readings. Wish me luck!!

  4. Our pediatrician signed the form this morning (SO worth the $20 copay) and I emailed it back to Dexcom. That SHOULD be the end of it. Thanks so much for prayers!

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