Many of you may have heard by now about the newly created health insurance reimbursement codes for Continuous Glucose Monitoring Systems (CGMS). Sounds exciting. But what does it really mean?
As anyone who’s ever run into billing snafus with their health insurance knows (is there a PWD who hasn’t?), you’ve got to have these numerical billing codes assigned, and also correctly submitted, for any medical service or treatment in order for said treatment to be covered by your health plan. Without codes, those of us struggling to obtain coverage for new CGM technology were lost in space.
So the establishment of new codes for each separate component (A9276 for the sensor, A9277 for the transmitter, and A9278 for the receiver) is a big win for us, right? Weelll, sort of. It seems one could take a glass-half-full or glass-half-empty view.
The JDRF is delighted, after lobbying so hard for the codes for at least two years. They told me so in an email that was surely distributed around the country. Medtronic is delighted, too, having sent me an email stating: “The creation of three separate level-II HCPCS codes for subcutaneous disposable sensors, external transmitters and receivers reverses the agency’s decision last year to deny unique codes for the new technology. Medtronic is encouraged by this CMS decision, and believes it to be a major step toward CGM reimbursement for all patients who can benefit from monitoring their glucose in real-time.”
Goodness, I hope they’re right.
“For some reason everybody thinks that if you have dedicated codes that it will improve reimbursement for the new technology.
It simply isolates these claims and makes it easier for the insurance carriers to more efficiently deny claims for cgms. Eventually we will use these codes to process hundreds of millions of dollars worth of medically necessary kit. However in the meantime, be prepared for a step backward in the fight to secure reimbursement. We will just have to fight harder, be more persistent and with dogged determination to make our insurance carriers understand that cgms is a requirement and not an option for people with diabetes.”
And I do wonder, in light of recent remarks by certain prominent diabetes spokespersons, if he’s right about the big fight ahead.
Essentially, it’s good to remember that “codes” and “reimbursement” are not one and the same. The coding can aid coverage, but by no means guarantees it.
What we’re really going to need to secure widespread coverage is data, data, data — as much published evidence as we can get that CGM impacts people’s outcomes with diabetes. One early example is the Medtronic Star 3 Trial, aiming to show that patients using CGM systems spend less time experiencing hypoglycemia, and that their glycemic variability and A1c scores improve.
All of you out there already using CGM are probably thinking, “Duh!” But we have to be patient patients. The Powers That Be need to organize and track and document the requisite official studies to get these outcomes in black in white. Otherwise, we’ve got no leg to stand on.
All in all, authorities tell me, we’re probably not looking at widespread coverage for CGM systems until 2009 (if we’re lucky). Is that good news or bad news? Depends on your view of the glass.