CGM (Continuous glucose monitor) refused by insurance.. twice

Finance, Taxes, Banking, Insurance and Retirement
1
Dear all, I need your advice. I am type 1 diabetic and I had a 'honey moon' of treating diabetes with pills for 3 years, but the time has come and I need insulin.

I have requested to my insurance (CSS) to cover the costs of a CGM device. My diabetologist of course wrote a letter to the insurance and she also sent my diagnosis (A1c > 9% at that moment). That was in the middle of September 2022.

Since then, I have received twice rejection letters for my application, and I don't really know what to do.

Are there any diabetic people which use CGMs? If yes, which insurance company you have?

Thanks all in advance,

sad, sweet diabetic.

2
Generally in France and UK the one that is covered is Abbot's Freestyle Libre. I self-paid for it a couple of times here for an experiment. Of note is that the readers used to have a life of 30 days and now they've been reduced to 14 so more-or-less doubled in price. I can't help you any more than that.

3
Yes, I asked to have the Abbot's Freestyle Libre. It's ~65CHF per device, so around 130CHF per month. On top of the 450CHF for the insurance itself...

4

Check this document for more info: https://www.bag.admin.ch/dam/bag/de/…01.01.2020.pdf

Insurance should pay if:
Sorry, all in German but it’s official information from the BAG.

5
Thanks, I am aware of this document and at the point of first application in mid September, my A1c was 9.1% and that qualifies me for reason a) HbA1C-Wert gleich oder höher als 8 %

6
I don’t understand the rejection as you obviously qualify. Is your Dr. a diabetaloge? If not perhaps they won’t accept a prescription from him. Can you call them and ask?

I happen to have 4 FreeStyleLibre 1s that I don’t need. They expire in Spring 2023 so still valid. I am now using the fsl 2s. If you PM me your address I’ll put them in the post to you, no charge.

Please note you either need the original reader or app to start the sensor.

PS my A1c is 6.3. These things really do change your life!

7
Actually are you certain that you’ve been diagnosed as a Type 1? AFAIK Type 1s always require insulin while many T2s can be treated with oral medication (pills). Some require insulin. While the symptoms are similar they actually are different diseases.

I don’t believe T2s are eligible for reimbursement of CGMs.

8
I don't understand either why they reject me. The doctor is a diabetologist. Unfortunately there is no number on the letters from the service responsible for this decision and I tried to call the CSS call center, explain the situation and they hang up on me.

Thanks a lot for your offer, if I don't manage to resolve the situation soon, I will contact you!

9
Yes, it's type 1 that shows up around 30s (also known as LADA). Myself is for sure type 1 because of the existence of anti-bodies.

10
So not Type 1 exactly. This could be the problem. You should talk to your Dr. and ask her to intervene with your insurance company.

11

Did you check with your doctor ? Maybe they can prepare a letter that addresses whatever problem CSS is having with the prescription, or call CSS themselves to work out what the problem is ?

LADA is not typical Type 1 - it has its own special category. I wonder if the health insurance has you listed as Type 2 ?

And are you asking for CGM or Freestyle Libre - they are not the same thing.
Although the marketing now has them both labelled as ‘CGM’ - Freestyle Libre is flash monitoring whereas Dexcom is continuous - but Freestyle has just come one step closer - however on the Swiss medical system they may be classified differently. I don’t know.

My recommendation would be that if your HbA1c is that bad, you ‘upgrade’ to a specialist Endocrinology doctor, and not a generalist that also ‘does’ Diabetes. My son sees the top expert at the Unispital - they have access to all the latest treatments, information and research…

Freestyle Libre is great… it’s worth fighting for…although it’s still expensive…

Write a letter to CSS - don’t assume you can sort it over the phone. I am sure there is a name and address on the letter - and very likely it’s a computer generated decision based on whatever is coded in to their system for your diagnosis and prescriptions and the permissions allowed for your doctor…

AND second step, if a letter does not sort it out - have you joined the diabetes association ? I am sure they can answer your questions and clarify what you are entitled to get through the basic health insurance…

adding a link for more info: https://www.usz.ch/fachbereich/immun…toantikoerper/
It’s clear that they consider LADA a ‘third’ type of Diabetes and that it is often diagnosed as Type 2 as it’s not immediately insulin-dependent whereas Type 1 is usually insulin dependent at diagnosis.

12
Swisspea,

The recently released FSL3 is a CGM. It communicates continuously with it’s app on your phone. Both the FS1, with an additional transmitter, and the FSL2 can be hacked to be CGM This is what I do.

Abbotts poor software is why I do it. Let me know if you would like a link to xDrip or xDrip4iO5, software to capture FSLs readings. And also having Nightscout gives you the ability to share the data on other devices, e-watch, other phones, some pumps.

13
I've been using FSL for about 3 years now and switched this spring to the new FSL3, which is to all intents and purposes a CGM. Even my insurance, Assura, well known for being picky, has reimbursed my FSLs, though they are a bit slow about it. I am a Type 1, though only diagnosed as such at the age of 50 or so.

The new FSL3 cost the same as the previous sensors, so there is really not much point in using the old sensors, as the FSL3s are smaller and easier to use as they don't need to be scanned, other than to start them off.

There must be some way to get in touch with your insurer. Even Assura has a phone number and whenever I call them, they respond fairly quickly. If you don't manage to phone them, write them an old-fashioned letter asking for an explanation. Don't bother with e-mails, the insurers are very old-fashioned and don't react.

14
Out of interest. Why do these things expire after 14/30 days as single use items rather than something you can change the battery? Is it just pure profiteering?

15
CSS have local offices in almost every town and even larger villages. Much easier to pop in, bring someone with you who can interpret if necessary. Much easier than the phone.

16
No. They work by inserting a fibre into your skin. The fibre reads the sugar level in interstitial fluid between cells and an algorithm in the software converts that to an equivalent blood sugar level. The fibre is not expected by your body and your immune system is constantly attacking it. 14 days is likely the best average period that the sensors remain accurate. Initially the US FDA only allowed a 10 day validity there but by studying results from the rest of the world have decided that 14 is OK. I admit, although being one of the first FSL users here, I have never seen a 30 validity period.

There is at least one company (bubble) that claims to be able to fool the Abbott software into allowing longer validity but results from that have shown to be disappointing. Regardless of the cost per unit, accurate results are absolutely key to maintaining good results. And bad results can be fatal.

17
Yes, the doctor said she can't do anything else. I am trying to contact CSS's specific department to ask the reasons of refusal, but didn't manage yet.

I am not sure how the insurance has registered me, my diagnosis from the doctor which was sent to insurance, says Type 1.

I will try to write a letter myself explaining the situation, saying why I qualify with the MiGeL points and attach the diagnosis of the doctor.

May I ask what is the insurance company of your son?

Thanks for the link for the association, will look into int.

18
Though they could of course design the fibre/sticker to be the cheap disposible element and the remainder re-usable with rechargeable battery.

19
They certainly could and they should. As I understand it the reason they are sticking with a single design is that each design change requires regulatory approvals, in Europe, Switzerland, USA and many other countries. Apparently the costs of this and duration of getting approval are why we are not seeing progress. The battery thing is a particular fault. I used to break open a used sensor to extract the battery, which usually still retained a charge of 90% plus. But I never found another use for those batteries so just ended up dumping in the battery box at the déchetterie. I now dump my used sensors there.

20
This is what you should do. If you could get a letter from your Dr, confirming your T1 diagnosis that would help too.