Questions About My 2nd Level Insurance Appeal...?

Question

I am battling Aetna PPO to cover a diabetic DME (Continuous Glucose Monitor). I have followed every step/policy Aetna has asked of me to complete this appeal process. I am ANGRY that when I ask something of them, they do not even acknowledge my request! In my last appeal letter I specifically asked for 4 things from them if they denied my appeal again:

1. Study references they used to deny my appeal (URL format)

2. Full listings of financial and other relationships which any insurance companies and other payers (such as Medicare/Medicaid, Military “Tricare”, VA, etc.) have with their study authors.

3. Medical license numbers of their decision maker(s).

4. An appropriate legal contact’s address.

My questions is: Do I just go ahead with my next appeal, or do I call them up on not supplying me with the information that I requested and demand that they do it?

Thanks for your help

Marcy

Answer 1

The answer to your questions can be found on their public website. They sited more than 77 resources, some were medical organizations. If you want industry standard information go to the fda's website. Why do you want the license #s of all the doctor's who participated in research? I'm not sure how that would help your appeal...

This device is still usually considered experimental by every insurance company I checked online. If you are trying to do something with the information provided, good luck. If you're asking in the hopes they can't provide you the data, I'm not sure how to help. But, seemingly, my post answers most of your questions.

Corporate address:

Aetna Inc.

151 Farmington Avenue

Hartford, CT 06156

USA

Continuous Glucose Monitoring Devices:

http://www.aetna.com/cpb/medical/data/1_...

Aetna considers continuous glucose monitoring devices (e.g., MiniMed Continuous Glucose Monitoring System, Guardian Real-Time Continuous Glucose Monitoring System, and the DexCom STS), which are used to continuously monitor diabetic persons' blood glucose levels over a three-day (72-hour) period, medically necessary for persons with type 1 diabetes who have either of the following problems in controlling blood glucose level, unresponsive to conventional insulin dose adjustment:

   1.  repeated hypo- and hyperglycemia at the same time each day; or

   2.  hypoglycemia unawareness.

No more than two CGMS monitoring periods are considered medically necessary within a 12-month period. Aetna considers the long-term use of continuous glucose monitoring devices for home self-monitoring of blood glucose experimental and investigational.

Answer 2

You go ahead with your next appeal.  

they aren't required to "honor" any requests.

The legal contact for complaints, is your state insurance department - you can get the contact info on their website.