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Insurance and the Games We Play

** this post originally appeared on TuDiabetes on April 15, 2009.  Given that it is National Chronic Illness Awareness Week, I thought describing the insurance hoops we often have to jump through was a relevant topic

Well, after a battle with Coventry Healthcare of Kansas, I received a phone call today telling me that my appeal had been approved and that I would be able to get coverage for a CGMS.  I may be the first person that Coventry has approved for such a device.

What I really learned tho, is how an appeal process really works.

When you appeal, Coventry (and maybe other companies) will ONLY send the information that you include with the appeal itself. It is up to the reviewing doctor then to get other information either from Coventry or your doctor.

My first claim for a 72-hr CGMS test was denied as experimental and the doctor seems to have simply assumed that I was a Type 2 based upon my age. He then proceeded to give me all sorts of evidence that CGMS systems were NOT experimental IF I was a T1 and on “intensive insulin therapy” (ie a pump). I provided that information (which my insurance company already had) and the test was approved.

I then applied for a CGMS device of my very own. The authorization was denied as being experimental, as I expected. I then appealed and quoted all the evidence from the previous denial that it was not experimental. They gave me all the evidence I needed to show that it was not experimental.

Basically, IMHO, the denial was automatic, the first appeal review was half-arsed and that is why they got backed into a corner and basically had to authorize the device.

So how to appeal from now on. Assume that the person reviewing the claim will NOT seek any other information. Include any information that you feel might be applicable. Do not waste an initial appeal finding out why something was deemed experimental. Find out the basis of the experimental decision, preferably in writing, before you file your appeal. Most plans have 2 appeal levels, after that, it’s off to court you go.

So, don’t be afraid to appeal. Many people will get a denial and go “I really need that treatment, but there’s nothing I can do”. The insurance company HAS to explain the appeals process to you, it’s the law. You may not always win, but at least you are fighting for what you need to live long, healthy life.

It only takes some time and patience to file an appeal. Get supporting letters of medical necessity from your doctor, gather all the information you can from every reliable place you can find it. Write a concise, non-emotional, professional letter that ties together all the information you are providing.

As a disclaimer, our insurance plan is a self-funded ERISA plan, which are regulated by the US Department of Labor as opposed to the Insurance Commissioner of your state. Being self-funded gives the plan-administrator a lot of flexibility in approving things since our company pays for the coverage, not Coventry. I asked our administrator today if she had spoken to anyone at Coventry about this and she said no, so it seems that Coventry approved this on their own. However, the story could have been different if the plan had been premium-funded. After a second level appeal, an ERISA plan requires the involvement of the Department of Labor to appeal past that point, I have no experience with that aspect.

If my plan had not been ERISA, after the second level appeal I would have then appealed to the Insurance Commissioner for the State of Kansas.

Remember, insurance companies make more money by not paying out claims. Sometimes denying a claim is justified, sometimes it is predatory.

I’ve recently gotten very tired of predators.

Thanks for stopping by,


Today’s snarky comment: Why are you still here?  It’s Friday for crying out loud

  • Let me play a lil devil’s advocate.
    Now I abhor insurance companies as well for nickle and dime games they play all the time, it is usually very frustrating and annoying at best but I have also been on the other side of the isle, with no insurance and insulin, strips, pumps,lancets and all the other out of pocket coming up to hundreds of dollars a month that I could nay afford at the time.
    Honestly at the end of the day, it is a choice between two evils but I will jump through hoops any day, kicking and screaming mind to make sure I can afford my diabetic supplies than go without because I couldn’t afford my meds.
    I am a T2 so my needs are not as magnified as a T1 I shudder just thinking about how a T1 would manage without insurance.

  • My endo believes that automatic denials are a standard operating procedure for some insurance companies (for example, WellPoint-Anthem BC/BS is notorious among doctors for doing this — the idea is that only a limited percentage will then appeal so they can avoid paying those claims with very little effort from the insurance company simply by denying it automatically. You are also correct in that the appeal reviewer will not necessarily have all the information about your appeal, nor will they seek out any additional information (they get so many appeals, its easy to understand why they wouldn’t) which is why it is relevant to save documentation of every item that was sent to the company in your appeal. I’ve started to get USPS return receipts for everything, that way I can go back and say “Well, I have a return receipt signed by on , so don’t tell me you never received it — I have proof!” I have also taken to getting names/addresses/extension numbers for any individual I speak with at the insurance companies; it can save time by enabling you to avoid automated Voice Response Unit (VRU) hell if you have to call back, and makes the best use of my time. Thanks for a well-written primer; it may save someone else a lot of steps they would otherwise learn based on trial-and-error!

  • Congratulations on winning your appeal! I was also denied last year and won my appeal. Like you, I sent a very detailed letter as to why I needed it and studies showing it would help. When the woman from my insurance company called to let me know that they had approved it, she told me that I had alot of very useful information in my letter.

  • You’re right…they are predators. My insurance didn’t cover most of my short term disability during my twin pregnancy last year which shocked my doctor who explained high blood pressure, 2 dislocated vertebrae, severe anemia, and type 1 diabetes was pretty much all a good excuse to take it easy at home instead of continue at a high stress corporate job. I only got a small amount covered because I kept at them and went through a major appeals process. Urghh…I’m still fuming….

  • I’ve always had a terrible opinion of insurance companies, but mine (BCBS of Oklahoma) has actually been pretty great since I was diagnosed. They approved me getting the pump a lot earlier than they normally do (after 3 months of injections, rather than 6), and they approved my Dexcom… no appeals necessary. I don’t know if it’s because these things I’m planning a pregnancy once I’m healthy enough, because it’s considered unusual for a 30 year old to be diagnosed T1, or if they’ve just clued into these being essential tools in preventing complications… but wow, they came through when I fully expected them to provide me with the absolute bare minimum they could get away with.

    Go figure. I still think the whole system needs serious revision, but I’m not totally convinced my insurance company is evil anymore!

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