Confronting Insurance Denials: Jessica’s Story

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Jessica Von Goeler, DPAC Advocate

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Reading the news from my insurance company, I was crushed.

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“After review, we have made the decision about your health care coverage. Coverage for the requested medical device has been denied because we have not obtained clinical information from your provider to determine whether or not the device is medically necessary.”

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This made no sense. I had just been discharged from the emergency room for my third visit in less than a year due to hypoglycemia unawareness. Surely, my resulting severe lows were costing them more money than a CGM. My endocrinologist provided decades of evidence of medical necessity and highlighted the savings in just preventing just one of these lows.

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I had been here before. Letters of Medical Necessity, Pre-approval, Coverage Denied, Health Insurance Appeals. Every time, it leaves me asking, “Do the people denying me access to medical care even know the first thing about diabetes?”

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Turns out, no. The MD assigned to review my claim was a part-time retired dermatologist.

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It seemed so obvious to me. I don’t feel my lows and they are severe lows. As a result, I need help. A CGM could tell me when I was low and prevent more severe lows. The dermatologist wasn’t convinced this was medically necessary.

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I fought the insurance company and won. I used the same methods I had in the past and since:

• Followed the insurance company’s appeals process – it is the only way to engage them.
• Partnered with my endocrinologist and CGM company- their experience working with insurance is priceless.
• Tracked every communication between the insurance company, endocrinologist, and CGM company – a record of communications is an important tool working with state agencies to mandate coverage (I’ll come back to this).

• Was deliberate in my communications – words like clear act, discrimination, and negligence are attention-grabbing.
• Repeated the same three messages in every communication:

• CGM is FDA approved and supported by extensive clinical studies.
• Approval will save my insurer thousands of dollars in future claims.
• It’s an illegal act of discrimination against people with diabetes, to deny access to life-saving therapies.

• Called elected officials and shared my personal stories with hypoglycemia unawareness, how the CGMS would change that, and asked them to call my insurer and request they approve my claim – personal with an ask is the best way to engage elected officials.
• Contacted my state’s Office of Patient Protection and asked them to intervene – they can mandate coverage. (Your State Attorney General can help you find the office in your state. Find your Attorney General here: https://www.naag.org/find-my-ag/).
• Used my strategies in parallel – don’t wait for one to fail. Do them all at the same time.

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Every claim I’ve fought has been life changing. With the CGM approval, I brought my A1c down into the low 6s without severe hypoglycemia. On my wedding day, I didn’t worry about going low and needing help. I was healthy enough to get pregnant and have a baby. Things I never thought possible.

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