#B027 and Me: An Update on a Reimbursement Odyssey

by james s. hirsch

In the last issue of diaTribe, I described my efforts to gain reimbursement for my continuous glucose monitoring system. I had worn the DexCom SEVEN as part of a six-week trial and had had good outcomes - my A1c dropped from the mid to high 6's to 6.1, and the alarm detected imminent hypoglycemic episodes. Unfortunately, my insurer, Harvard Pilgrim HealthCare of New England, rejected my request for coverage of the sensors ($60 a week) as well as my appeal.

So my final effort was to seek an external review from the Massachusetts Department of Public Health. DexCom helped with my appeal, which included letters from me, DexCom, and my physician, as well as recent medical records showing the improved A1c. The appeal cost me $25, and the package was sent on December 12.

The decision didn't take long.

On December 22, I received a letter from a company called Imedics (Independent Medical Expert Consulting Services in Lansdale, Pa.), which had been hired by the Massachusetts health department to rule on my appeal. The actual reviewer was identified only as "#B027," who is "board certified in Internal Medicine and Endocrinology. Currently holds a position at a university medical center as a clinical professor."

#B027 got right to the point. "Dear Mr. Hirsch: The independent reviewer has overturned in whole the original decision in regard to your external appeal."

Male or female, I could have given #B027 a kiss right then and there.

#B027 recounted the facts of the case, noting that I had had a car accident from a hypoglycemic experience and that my control improved with the DexCom. Harvard Pilgrim did not dispute those facts; rather, it rejected reimbursement because my health care plan states that "continuous glucose monitoring systems are covered when used in conjunction with an external ambulatory insulin infusion pump," and my insulin pump is not physically linked to my CGM - it's not a closed-loop system or even a partially closed-loop system.

But wait! #B027 found a loophole in this closed-loop logic. "The definition does not explicitly state that the monitoring system must be physically attached to the pump," #B027 wrote. "It merely states that the system must be used with (in conjunction with) the pump."

So by redefining the word "conjunction" - concluding that it does not imply "physically linked" -- #B027 decided that the DexCom is indeed a covered benefit. #B027 also noted that the sensors will cost Harvard Pilgrim far less money than a new pump that is attached to the sensors.

Obviously I'm pleased, but the entire experience is a window into how dysfunctional our reimbursement system is. #B027's language more closely resembled a legal brief than a medical endorsement, and why wouldn't #B207 rule in my favor? #B027 is a doctor, and doctors are supposed to care about patients. They don't care about an insurer's bottom line. Not surprisingly, DexCom told me that it's won most of its external appeals.

The moral of the story? If you're seeking reimbursement, be organized, be persistent, and get the decision out of the hands of the insurer as soon as possible.

And if all else fails, ask for #B027, and give the good doctor my regards.