My son is 5 and just diagnoised on 12/31/12 (what a way to ring in the new year). This has all been a whirlwind the past few months. And now I just got the letter from insurance they denied my son a CGM. I am so angry! (to say the least) I am working on an appeal as we speak. When we submitted the request I even sent a letter from our endo saying it was medically necessary for him. Insurance stated he needs to have 4 blood sugars below 50 in one month or been in DKA multiple times for him to qualify for a CGM. I was blown away by this responce. Are they serious? The reason to have the CGM is to prevent those things from happening. I want to get one in place so my son can have the freedom to continue his life as normal as possible. Does anyone have any ideas/thoughts on how to fight them on this?
The appeal should work, and what I can tell you from experience is that you need to be very persistent. Your doctor has to be the one to write the medical necessity and say he has been having lows. if your doctor writes it in the correct language you should get covered. It takes a couple of times sometimes. Hang in there!!!
Gina is right on. CGMs are expensive, so you may have to appeal multiple times with the insurance company.
Be sure to include in the appeal documents that your son is a heavy sleeper and may not wake up from an overnight low. Also that because he is school age it will allow his teachers and daycare providers to know he is low before it becomes life threatening.
I know CGMs give peace of mind, but be assured that even if it takes a while to get one your son can be totally fine without one. When a person has low blood sugar the body has a sympathetic response and releases adrenalin, which will wake the person up and cause the shakiness, sweating, and other low symptoms. Over time if a person with diabetes has too many highs and lows, the body doesn't have the same response, but it takes many years (at least a decade or more) or extreme highs and lows until that happens.
I've had diabetes since age 4. I survived my childhood without a CGM. I did use a CGM for a few months as an adult, but didn't think it was useful enough to continue. Until CGMs are accurate enough that I no longer need to test, it's not worth using up the skin I need for pump infusion sites to use one. Also, my hypoglycemia unawareness disappeared after I started using a pump. If I had unexpected highs or lows then a CGM might be worth it.