Those CGMS Insurance Codes

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?

Cgm_got_codes 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.

But Kevin McMahon, President of Diabetech and avid blogger, had this to say on his recently launched “CGMS Central” blog:

For some reason everybody thinks that if you have dedicated codes that it will improve reimbursement for the new technology.

Wrong.

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.

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10 Responses

  1. Scott K. Johnson
    Scott K. Johnson November 12, 2007 at 7:56 am | | Reply

    I hate the battle with insurance. It’s a double edged sword isn’t it?

    Everything always comes down to money I guess. As frustrating as that is for me and you and all our brothers and sisters out there.

  2. Challenge Diabetes
    Challenge Diabetes November 12, 2007 at 8:54 am | | Reply

    Announcing CGMSCENTRAL.COM; a site dedicated to helping people secure reimbursement

    Emails, Blogs and Groups on the Web are great for some things and not so great for others. Enter the power of the Wiki plus integrated tools for capturing important information and packaging it so that people can quickly and efficiently reference fact…

  3. JasonJayhawk
    JasonJayhawk November 12, 2007 at 9:03 am | | Reply

    Coverage by 2009 isn’t bad, but I think some people are still fighting insurance companies just to get the daily strips they need for single tests.

    I think the wait will be longer than 2009, considering how slow it takes for something like this to catch on. If we see basic coverage for CGMS by 2009, I’d be dancing for joy! But in the mean time, insurance companies would rather pay for two emergency room visits per year than for one year of CGMS supplies.

  4. Kevin McMahon
    Kevin McMahon November 12, 2007 at 9:06 am | | Reply

    Thanks for calling attention to this Amy. I hear about too many people sitting back and waiting to begin working on their own reimbursement ‘until the codes are approved’. If we look at the insulin pump as an analogy, we know there are still people fighting for reimbursement on a case by case basis and one would assume that the benefits of pump therapy had been universally accepted long ago.

    Also, to clarify, cgmscentral.com isn’t a blog. It’s a patient resource including lots of tools to be used by patients for patients as they work toward securing their own reimbursement. While the site does offer the individual their own blog, it also includes Wiki software for shared page editing (factual data), newsletters, surveys, polls, forums, etc… It’s the answer to anyone who has ever felt silly asking the question that’s already been answered over a hundred times but they just can’t find the information.

  5. Bernard Farrell
    Bernard Farrell November 12, 2007 at 11:14 am | | Reply

    I met with a group of fellow pumpers on Saturday. At one stage we started talking about CGMS and reimbursement. The general agreement seems to be that it’s hard and there are a few reasons that improve coverage (but don’t guarantee it). These are: hypo unawareness; planning for pregrancy if you’ve got diabetes; lots of emergency room visits; and lots of glucagon usage.

    The last one was just one case that someone knew of. It’ll be interesting to watch Kevin’s site to see if other coverage reasons get publicized.

  6. Anne
    Anne November 12, 2007 at 4:44 pm | | Reply

    Of course it’s helpful if the insurance companies pay for everything but the greatest expense in these devices comes from the sensors, which have to replaced the most frequently (weekly for Dexcom if you go by the book). An insurance company that may not want to foot the whole bill may at least be able to help cover the sensors with these distinct CPT codes. If it’s anything like BG meters, eventually they will practically give you the meter device in order to get you hooked on their product. Honestly my first reaction to the cgm I was using was that I didn’t even feel justified arguing it with my insurance because it was so unreliable for me. They seem to have greatly improved the sensors since then, though, or else I’ve just figured out the sites that work for me. Now that there are codes, I may be ready to start my battle for coverage.

  7. Andrew
    Andrew November 13, 2007 at 7:33 am | | Reply

    It would be great to know if anyone has been able to have their CGM covered by insurance. And if so how did you do it (eg. studies submitted, brand of CGM, name of insurance company,…).

  8. Kevin McMahon
    Kevin McMahon November 13, 2007 at 11:28 am | | Reply

    And if any of you who have been so fortunate so as to have been granted reimbursement cares to respond to Andrew’s plea for help in his quest, you should post that detailed information (names, phone #s, evidence, strategies, etc…) on cgmscentral.com

    Posting that info or only summary info on a blog like this doesn’t really help the person asking the same question next month.

    Why so few comments on such a hot and salient topic so critical to this community?

    Where’s the buzz???

  9. Cynthia Rice
    Cynthia Rice November 13, 2007 at 7:41 pm | | Reply

    Amy –

    Thanks for sharing the information about codes, and underscoring that while codes can aid coverage, they by no means guarantee it. JDRF is funding a large clinical trial to gather evidence needed for reimbursement, and has posted tips for how to seek coverage in the meantime — go to http://www.jdrf.org/artificialpancreas and click on ‘insurance coverage.’

  10. Kevin
    Kevin November 14, 2007 at 4:05 am | | Reply

    I see this as a help for those that are denied coverage for the basis reason of “there’s no proper billing code.” However, I don’t see it any much of a step forward besides that. I think the cost ultimately needs to come down. Insurance rates for a single person are averaging around $400 a month I believe. That’s $4800 a year.

    Most on a CGM also use a pump. If going by the rules for everything, the cost for cartridges, infusion sets, CGM sensors, etc. would be $17.17 a day roughly. In a year, that is $6266 and that doesn’t even cover the cost of the initial device (Add $1750 for a pump every year) or BG strips and insulin. So diabetics are already a huge loss for insurance companies which is why most states mandate coverage (no federal law yet.)

    So what am I saying? I’m saying there’s no real benefit for insurance to cover all this technology. Yes, it may prevent an ER visit once a year, but even then, that only comes out to at most maybe $2000 for an overnight stay. And with proper education, most can recieve just as decent control with BG strips and MDI. And I haven’t been to the ER in 8 years, and only been pumping for 5 years. So the ER excuse is a bunch of bull in my opinion.

    While I love my pump and wouldn’t do without it, I see why insurance is fighting so much against it. To cover it, they’d have to increase premiums for all, which seems to be a huge debate right now for the election campaign, employees in the workplace, union contracts, etc.

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