Responding to an insurance company's denial   (March 3, 2008)

Last week, I discussed part of my reply to an interesting question I'd received, in a SharePost titled Depending on a Tool. Today, I thought I'd share my thinking with you today about my answer to the rest of the question, about an insurance company's denial of payment for a diabetes device. (I've changed the text of the e-mail slightly, both for brevity and to maintain anonymity.)

"My mother has had type 1 diabetes for over 40 years. She has been using an insulin pump for many years but controlling her blood sugar has become increasing difficult, as she suffers from gastroparesis, which makes digestion and consequently her blood sugar incredibly unpredictable. She has also found it harder and harder to recognize the onset of hypoglycemic events which has led to countless occasions in which she has required assistance. She has been found unresponsive, sometimes combative and always humiliated by these experiences. Just last week she woke up on the kitchen floor with head contusions. My mom is now living alone which has left me and my siblings terrified for her well-being.

"Here is our question: her insurance company has twice denied CGMS as an "experimental or investigational" device. We don't know what to do or where to turn. This is not something we can pay for out of pocket, but are increasingly afraid that we will have no other option. My mother's life depends on this device. Do you have any information that may help us convince insurance that this is a necessity?"

Last week, I replied about the CGMS question. Here are my comments on the insurance issue:

"Arguing with an insurance company is always a multistep procedure.

"First, has her diabetes specialist written on her behalf? Does your mom have copies of the correspondence? The letter must say that the device is "medically necessary", and should document blood glucose levels, and what sort of assistance was required -- was it help by family or taking her to the Emergency Room, or what?

"Second, don't assume that the letter was received, if mailed or faxed to the insurance company. Send the letter again, this time by certified mail, with a return receipt requested.

"And a copy should go to the Medical Director of the insurance company, not just to the routine address.

"Also, send a copy to your mom's employer, if her employment is funding her insurance. And talk to the Human Resources department at her company about what might be done from the employer to help.

"Next, plan on rejection (which it seems is already occurring). Write again, and next time, make it clear that a copy is going to her employer (if employed) or to her Congressmen (if government-sponsored insurance).

"And finally, document everything!

"I have said, only partially in jest, that the first time you write, they throw the letter away. The second time they read it then throw it away. The third time they read it and write back. And the fourth or fifth time, you may eventually find a sympathetic soul who will allow the expense.

"Keep on trying."