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August 7, 2007

Insurance/Costs

Question from Alabama, USA:

Our insurance company is not covering the Real-Time continuous glucose monitor that has been prescribed for my child. I was planning on writing a letter of appeal to the insurance company to accompany the endocrinologist's letter. Do you have any suggestions as to what to do or what to include in the letter?

Answer:

I recommend that you contact the manufacturer of this equipment and ask them to provide you with any research or data published in a peer reviewed article as evidence of the benefit your child would receive from treatment using this device. Many health plans justify their coverage decisions on the lack of medical evidence or research to support a claim that one device or therapy would benefit over another. I recommend that you survey the medical literature for such evidence of the efficacy of this treatment.

Many health plans have established arrangements with preferred pharmaceutical and DME manufacturers; these are called exclusive formularies. Generally, insureds are required to pay higher co-pays or cover the cost of items and medicines/strips not on the plan’s formulary. As you are finding, your health plan contract probably provides for higher co-payments or coinsurance requirements for drugs and items not on their formulary.

You are entitled to file a written appeal to the decision of the plan concerning the use of a particular device. This appeal should contain documentation from your physician of the medical necessity of the use of that equipment. You must follow the timelines and requirements established by the plan to proceed with your appeal.

Please note: I am not a medical professional and am in no way endorsing the relative clinical advantage of one medical device or treatment modality compared to another.

DSH