Medicare-Dexcom-Smartphones:  Wait! Just Wait!

On 6/11/18 Medicare announced a change in policy to allow Medicare beneficiaries to use smartphones in conjunction with continuous glucose monitors.

“After a thorough review of the law and our regulations, CMS is announcing that Medicare’s published coverage policy for CGMs will be modified to support the use of CGMs in conjunction with a smartphone, including the important data sharing function they provide for patients and their families.

The Durable Medical Equipment Medicare Administrative Contractors will issue a revised policy article in the near future, at which time the published change will be effective.”

I have not blogged about this change for several reasons. 1) I am a lazy blogger. 2) I was quoted extensively in articles by Diabetes Mine and Diabetes Daily about my reactions to the announcement. 3) Most of my diabetes preaching these days takes place on Facebook. Today I decided to enter the arena with a blogpost because of the chaos on diabetes social media about what this announcement means and when it will be implemented.

Dexcom initiated the confusion with a 6/11/18 press release that states: “With nearly half of adults ages 65 and up using smartphones, Medicare diabetes patients are now able to use the Dexcom Share feature that allows users to share glucose information with up to five loved ones or caregivers.”

The problem is the word “now.” Now is not the near future as stated by CMS. Adding to the confusion is that a definitive policy was not communicated and standardized throughout the Dexcom organization and some Medicare beneficiaries were told by Dexcom reps that they could immediately begin using the G5 Mobile App. 

A couple of Facebook quotes:

“Damnit. Dexcom said it was good to go last night.”

“I called Dexcom support/app & software department again today they checked & confirmed that we could start using it as of June 11.”

“It would help us all if CMS or Dexcom would give a definitive statement about when. There is no hard statement about waiting.”

On top of that, Diatribe (whom I normally consider to be the Gospel of Diabetes) published an article that is not entirely correct. It states: “Like other users, G5 Medicare beneficiaries can now choose to view real-time glucose data on the G5 app only, the receiver only, or both devices.”

Christel Marchand Aprigliano of DPAC who has met extensively with Dexcom and Tandem in regards to the Medicare negotiations responded on Facebook: “The receiver will still be part of the system. It is still required as part of any Medicare contract. The usage of the app will be in addition to the receiver.”

She also stated:

“While I can’t speak for CMS (Who will obviously have the final say), the meeting on Wednesday was that it would be receiver + smart phone. The receiver is durable medical equipment and the modification of language will reflect the addition of smart device (but not the purchase of said smart device).”

The date of implementation for the policy change is somewhat murky. A Dexcom official confirmed with Medicare diabetes advocate, Larry Thomas, that: “It becomes official on June 21. The technical correction notice must be updated in 10 business days from the notice.” Diatribe also wrote: “According to Dexcom, the deadline for the Centers for Medicare and Medicaid Services (CMS) to update the coverage policy is June 21, if not sooner.”

But Christel cautions us that regardless of date: 

“Do NOT download the app until the actual physical ruling has been changed.”

The last quote that I will share is a June 14 Facebook posting by Larry Thomas about his conversation with a Dexcom Medicare representative:

“The old regulations regarding NOT using the G5 app for Medicare patients are still in place and Dexcom representatives are still required and instructed to report you to Medicare if you are using the G5 mobile app until the rules are changed. This means not only will you be back charged if you are not in compliance, but you will possibly lose future coverage for Dexcom CGM supplies in the future i.e. you will become a cash-only patient with Dexcom. These are her words not mine. If you doubt them please call and speak with a representative in the Medicare department at Dexcom. Remember, just because a tech support person or app support person gives you the okay to use the app, it does not waive your responsibility to abide by the written contract you signed in order for you to get coverage by Medicare for the Dexcom CGM system. I have again requested Dexcom to send out an email to all of us affected by this situation to clarify that it’s “not a done deal yet” (again her words not mine) and have also reached out (again) to the media release department at Dexcom to change the media release so that people are not confused by this.”

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What you need to know if your Dexcom G5 is being reimbursed by Medicare:

1)  You are not yet allowed to use the Dexcom G5 Mobile App. You must wait until the revised policy is issued by DME Medicare Administrative Contractors (MAC’s) such as Noridian. If you use your smartphone before this revision is released, you are in violation of Medicare policy and risk losing Medicare reimbursement for your Dexcom G5.

2)  It is highly unlikely that you will be able to your smartphone exclusively without some use of the receiver. “In conjunction” means “with” and “combining” not burying the receiver in a sock drawer. IMO it is best to refrain from sharing your receiver-avoidance intentions on social media until the final CMS policies are released. Don’t give CMS ammunition to contrive stupid roadblocks to reasonable CGM use by Medicare beneficiaries.

3)  Do not call Dexcom at this time. Christel Marchand Aprigliano of DPAC told me: “Tell everyone to wait for the policy change from CMS in writing – Dexcom will put out information when it becomes available. Please kindly also remind them that the customer service department at Dexcom is trying very hard to provide good customer service, but it is not in anyone’s best interest to call – wait for the announcement published by Dexcom on the website (and I’m sure we will be announcing this as well.)”

4)  Nothing about this recent change in policy affects the use of the Tandem X2 insulin pump as a CGM receiver. Although Tandem and Dexcom are in negotiation with CMS, the current policy is that Medicare beneficiaries are forbidden from using their Tandem t:slim X2 pumps as a Dexcom G5 receiver.

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Special thanks to Christel Marchand Aprigliano of DPAC and Larry Thomas, bulldog Medicare diabetes advocate, for giving me permission to share their words.

Note that all bold text in this post is my emphasis and not that of the organization or person being quoted.

Diabetes Supplies under Medicare: Hard Work

Yesterday a couple of diabetes friends on Medicare got in touch with me to see how things were going with the reorder of my pump and CGM supplies.

One friend emailed: “Just checking in to see how your Dexcom reorder went. Did it ship?  My bundle arrived yesterday (Tuesday).”

I replied: “My Dexcom reorder has not yet shipped…. It is being processed today so I expect it early next week.”

She also mentioned: “I am interested to hear how it goes when you order your pump supplies for 2 day changes.”

I replied: “I think that I will be getting 4 boxes of everything which is less than the 45 sets I would like but more than the 3 boxes the previous lady said….”

A second friend checked in through Messenger giving me an update of his D-life and indicating that everything was going smoothly with his Dexcom orders and his life in general.

I mentioned: “I haven’t written anything on my blog in a while because I don’t have much to say these days. That’s actually a good thing.”

A few hours later things fell apart and my smiles turned into grimaces of frustration. And here I am writing a blogpost.

Let me say that my supply orders are not completely straightforward. I am lucky to escape the cold and snow of Minnesota in the winter and spend several months in Arizona. I am paranoid about medical supplies ending up frozen on my front porch in Minnesota and always double-check with suppliers that they are using the Arizona address. Secondly I am at a stage in life that I need to change my infusion sets every 2 days. My skin and tissue have gotten less durable as I’ve aged and 3-day sites leave me with inflammation at the insertion site, itching and rashes, occasional bleeding, and poor absorption. Fortunately I had been warned in December that in 2018 Medicare was only covered 30 infusion sets every 90 days and I needed physician clinical notes to override that restriction. At my December endocrinologist appointment, I discussed this with my doctor and ensured that she included this in the visit notes.

Before I describe my supply woes, I should say that it is not all Medicare related. Unfortunately lots of people with diabetes struggle with insurance and suppliers to get their supplies. I have been uniquely lucky that I never had problems before getting to Medicare. I am someone who had fabulous service from the universally-hated Edgepark and never had my insurance question anything. My orders reliably arrived 3-4 days after ordering. I am new to waking up in the middle of the night and worrying about getting the correct supplies (and enough supplies!) at the correct location when I need them.

You don’t need all of the details, but both Dexcom and CCS Medical have emailed and called several times in the last 10 days, each time with a different rep and no realization that the order has been already been discussed and finalized. A Dexcom rep called me yesterday afternoon to see if I was ready to confirm my supplies for this month. I said it had already been done but went through everything with him and confirmed that the order would be shipped to Arizona. An hour later I received an order confirmation shipping to……Minnesota. I called Dexcom and spoke with another rep who had to once again confirm the supplies I needed. She  placed a new order and canceled the order going to Minnesota. I think everything is OK and it only took 4 phone calls and 3 emails. And in 3-1/2 weeks I get to do it again!

CCS Medical has been equally attentive as I have received multiple emails and spoken with three different reps about my order. The first rep took my information, changed the shipping address, and indicated that I would only get 3 boxes of infusion sets. She told me that once my doctor’s clinical notes were received, I would be shipped the additional supplies required. A few days later a young man from CCS called and asked if I was ready to order. I said that I had already ordered but we went through it again. He confirmed that I would get 4 boxes of infusion sets so I assumed that they had received my doctor’s notes. After the Dexcom mess yesterday, I went online and checked my CCS order and saw that 3 boxes of infusion sets and cartridges were being shipped. But at least they were going to Arizona!. I called CCS. This rep confirmed the 3 boxes and said that there was no record of the young man’s call on Monday. She said that he didn’t work for CCS?!? She also said that my endo had not submitted clinical notes.

My endo’s office historically gets an A+ in promptly submitting required medical orders and clinical notes for my diabetes tech and supplies. But I called and faxed the office this morning and asked that the needed info to be sent to CCS again. I will keep following up with CCS because I absolutely require more than 30 infusion sets for the next 90 days.

My Thoughts: Medicare has not been horrible in providing what I need to stay healthy with Type 1 diabetes. Compared to many people with diabetes around the world, I am still a privileged patient. The issue has been that it takes a lot more work to ensure that I get what I need and what I am owed. Diabetes is always in the forefront because I have to keep checking that things are being handled correctly. It is like my life resets every 90 days and I have to start from scratch again. I have to see my endocrinologist every 3 months instead of my normal every 6 months. Now with Dexcom it’s a 30-day cycle due to Medicare rules.  My blood glucose numbers are similar to my pre-Medicare numbers. But diabetes is in my face all of the time. It is a bigger burden and I worry more.

But tomorrow I am going on a 9-mile hike. I have what I need today and tomorrow.

So FU Diabetes and Medicare and Dexcom and CCS.

I’ll deal with you next week.

Ordering a Medicare Dexcom G5:  What’s the Story?

Background:  In January 2017 it was announced that Medicare would begin covering the Dexcom G5 as a “therapeutic CGM” for patients with diabetes who met certain conditions. After months of delays where CMS, Dexcom, and Liberty Medical struggled to establish reliable procedures, we are now at a point where some Medicare beneficiaries are receiving Dexcom G5 bundles with payment by Medicare. I say “some” because Dexcom is totally overwhelmed by the demand estimated to be at least 20,000 patients. 

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If you are expecting this blogpost to be a “How To” manual, you will be sorely disappointed.

I am going to share my experience along with the stories of Medicare beneficiaries who have had an easy time getting their Dexcom Medicare bundle and those who have had or are having a horrible experience. I will provide some information that may be helpful, but I do not think that there is a magic formula for success. As I write this post, I do not know how to categorize my journey. I am 6 weeks into the process. I’ve made progress but I’m mostly mired in a black hole of no information with unanswered voicemails and emails.

Are there characteristics that separate the successful people from the chumps? Not from what I can tell although it is an absolute necessity that your doctor fill out forms correctly. Other than that, I think that placing a Dexcom G5 order under Medicare is a crapshoot. Some are lucky. Others are not.

I don’t have statistics on how many people are having an easy time getting their CGM versus those struggling mightily. People having a bad time are more likely to be online complaining and looking for help and I have seen a lot of negative stories.

Before I go too far I want to emphasize that I am a huge fan of Dexcom. After a few rocky years using Medtronic SofSensors, I switched to the Dexcom 7+ in 2011. The good results with that device were magnified with the release of the G4 in 2012 and my life was changed. The proof of success is I have not needed my husband to get me a glass of juice since 2012. I get lows but my Dexcom warns me in time to treat them myself.

The Good Stories

These are the people we want to be.

Joe:  “I contacted Dexcom about the Medicare G5 and was contacted by a representative who took care of everything and I received my Dex a week later! Sooo Easy!”

Ruta:  “My husband was using the Dexcom G5 CGM before going into Medicare. We directly ordered from Dexcom. The transition was flawless.”

Carol:  “I have to say at this point that I was feeling almost guilty about having my G5 kit and this wonderful new sensor. Other seniors were complaining on the Facebook group about all kinds of issues with ordering their G5.” (It took Carol 2-3 weeks from start to finish.)

Lloyd:  “I don’t remember exactly, but I think it was less than 2 weeks from phone call to arrival!”

Nolan:  “I got the phone call and email on 08/22/17. I filled out the AOB, etc. and sent them back, Dexcom sent data requests to my Endo. I was kept informed via phone calls and e-mails about processing steps. I got the official Dexcom e-mail with “Your Dexcom order has shipped” on 09/12/17. 8/22/17 to 9/12/17 is an excellent time frame in my view.”

The Grouchy Stories

Natalie:  “It took a long time — months — to get all the i’s and t’s dotted and crossed. If the doc misses checking off one box or not using the right word in their clinical report, your paperwork gets routed to GKW (God Knows Where) and it could be weeks before the doc is notified and Medicare can again begin to process it.”

Deb:  “Medicare’s rules make it far more complicated and time-consuming that it needs to be.”

Camille:  “Latest excuse: Medicare requires insurance company to purchase GCM through a Provider. Ins.Co.  cannot purchase it from Dexcom directly. My insurance (MHS Advantage) is particularly inept but my understanding is that they don’t have a contract with a provider so they’ll are working on that. (Bear in mind that they’ve had 11 months to do that.) Meanwhile, in the past year, I’ve had approximately 30 Lows (below 50). I live alone, I live in fear.”

Ginny:  “Medicare also asks for information that isn’t even on the forms. It took months!!”

Kathy:  “Back to square one. no supplies from Dexcom. a week of lame excuses.”

Another Kathy:  “I have been with Dexcom for 10 + years and they were always super good about returning messages. However since Medicare approved their G5 system, they are so far behind in responding that it has come to: if you hear from them at all you are lucky. I, too, am waiting for the email that was promised over a month ago and it never comes.”

Chris:  “Wow, just wow! I was willing to give Dexcom the benefit of the doubt, but not so much anymore. They have continuously dropped the ball. I’m usually fairly patient, but I’m beginning to feel like a crabby old lady.”

Helpful Advice

Carol:  “Not sure I have advice, except to hang in there.”

Patti:  “Stay on top of it. Ask for a contact person so you’re always talking to the same person. Call or email them every few days if it doesn’t seem like the process is moving.”

Sandy:  “Just know that my polite policy with customer service always gets more service than sass…”

Kathy: “So, just in case my information might help someone else, I will post what the tech support person told me today. He said that my chart notes should include: 1) the date of last visit, 2) type 1 or type 2 diabetes, 3) patient tests blood glucose 4 or more times per day, 4) patient uses insulin pump or multiple daily injections, 5) patient’s diabetes requires frequent adjustments of insulin.”

Bob:  “Managed care (Advantage) plans have a great deal of latitude in how they reimburse a claim. They are required by CMS to cover anything that would be covered by original Medicare. But they are not required to reimburse claims in the same manner as original Medicare.”

Other Information

Refills: Once you get in the system, supply refills are mostly a seamless process. IMO the Medicare requirement for monthly shipment of CGM supplies versus the quarterly shipment of pump supplies puts an undue burden on Dexcom and is slowing their ability to supply more Medicare beneficiaries.

My Personal Rant

It is unrealistic to think that Dexcom can immediately process the orders of everyone on Medicare who qualifies for a therapeutic Dexcom G5 system. At the same time Dexcom needs to communicate better with those of us who contact them. After my initial call it took several weeks for the assigned sales specialist to call me. After a first conversation with him and signing the AOB, I received an email: “We have a new update regarding your pending Dexcom order. We have recently requested new or additional documentation from your Physician’s office. We will notify you again once we have the approval.” That was great and I thought I was finally in the information pipeline.

That was 3 weeks ago and since then nothing. My account shows no open orders and my sales rep neither returns phone calls nor answers emails. My endocrinologist submitted my paperwork early in December. Calling my rep last week I was put on hold and hung up after an hour and ten minutes of piano music. I then called customer service who indicated that my endo’s paperwork has been received and they will follow through with my rep. I think that it is a realistic ask of Dexcom that once we initiate a Medicare order that we be able to see the status of the order online or at least receive regular updates.

My history is that of a “privileged” patient with Type 1 diabetes. I have had good insurance. My endocrinologist submits needed documents on time. Every pump and CGM that I have ordered has arrived within a week. Since 2011 I have had consistently good service from Dexcom. Even now everyone I talk to is friendly and helpful.

But now I am on Medicare and the process is slow. The biggest stress is not knowing what is going on. I need COMMUNICATION. I know that my order will eventually be filled and I trust that it will be before my stash of out-of-warranty supplies is exhausted. I alternate between being patient and as Chris said above, being “a crabby old lady.”

I don’t like to be crabby.

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To Order a Medicare Dexcom G5 in an Ideal World

Call Dexcom at 888-736-9967. Select Option #1 to place an order and then Option #1 again for Medicare. Another option is to submit your preliminary information online.

A Medicare representative will take your Medicare and other insurance information and you will be assigned to a Medicare Sales Specialist.

You will be contacted and required to sign a form:  Medicare Assignment Of Benefits, Authorization For Release of Information, and Acknowledgement of Rights and Responsibilities. This is a typical insurance form with the added provision that you promise to only use the Dexcom receiver and not use any smart device with your G5 system.

Your doctor will be sent the medical forms required by Medicare. He/she will complete them correctly and return them quickly.

You will receive a notice that your Dexcom G5 system is ready for shipment and a package will be on your front porch in a couple of days.

Voila!

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Thanks to everyone who shared their experiences.. I couldn’t include every quote, but your stories are important. We are making history—sometimes painfully—as we are the first to receive routine Medicare coverage for our continuous glucose monitors.

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Links

Latest Dexcom Medicare Update

Preliminary Dexcom Online Contact

Info Sheet for Providers

Dexcom Provider FAQ’s

Ed Tepper: Fighting Against Dexcom Medicare Restrictions

Negotiations between Dexcom and CMS addressing the requirement that Medicare beneficiaries use only the Dexcom receiver have reportedly not been going well. Diabetes Patient Advocacy Coalition (DPAC) has organized a campaign to lobby our congressional representatives to have this policy changed through legislative action. To read an overview of the issue and easily contact your members of Congress, download the DPAC app on your phone or tablet or go to the DPAC website.

Ed Tepper of Glen Allen, Virginia is affected by the smart device restriction and has chosen to advocate for change. Coming from a family with a strong history of Type 2 diabetes, Ed was diagnosed with T2D 11 years ago. After developing neuropathy in his feet, Ed worked with his endocrinologist to intensively manage his blood sugars using insulin therapy in conjunction with a CGM. In addition to being an outspoken advocate for people with diabetes, Ed is an active cyclist and triathlete.

Here is Ed in his own words followed by the informative presentation he shared with one of Senator Tim Kaine’s staffers.

Ed Tepper:  This morning I had a 10 minute meeting with one of the staffers for Sen. Tim Kaine (D-VA). The attached file is the presentation I left with him. It was a good meeting. There is a strong history of diabetes in the staffer’s family and he was genuinely interested in the technology. He promised me that he would forward the document to Sen Kaine’s health lead and would email me within a few weeks. I’ll follow up if I don’t here from him by year-end. By the way, Sen. Kaine is on the senate heath committee so he may have some influence there. Keep bugging your senators and representatives about this issue. (11/28/17)

Ed’s Presentation:

Medicare’s restrictive policies regarding Continuous Glucose Monitors put seniors at risk and potentially raise the overall cost of diabetes management.

Meeting with Marc Cheatham, Staffer for Senator Tim Kaine of Virginia. November 28, 2017.

Disclosure:  I am an individual who is living with diabetes and is concerned that Medicare’s restrictive policies regarding the use of CGM’s will adversely impact my ability to stay healthy. I am not employed or otherwise associated with any company that manufactures or distributes CGM’s or related items. I am currently covered by Medicare Part A, Part B and Part D and have a Medicare Supplement policy.

What is a Continuous Glucose Monitor (“CGM”)?

A CGM is an FDA approved device that provides continuous insight into glucose levels throughout the day and night. The device displays information about current glucose levels and the direction and speed of change, providing users additional information to help with their diabetes management. The CGM consists of three components: the sensor that is inserted subcutaneously, the transmitter that sends data from the sensor to a receiver, and the receiver.

To Medicare’s credit, in 2017 they started covering the cost of one model of CGM, the Dexcom G5. However, they have place restrictions on how we must use the CGM that causes undue inconvenience and creates dangerous situations for Medicare recipient users.

I have been using the Dexcom G5 CGM for about 2 years now (before being covered by Medicare starting September 1, 2017). I started using the CGM because I developed neuropathy in my feet and in consultation with my endocrinologist decided that I needed to maintain better control over my blood glucose levels. Using the CGM has helped me understand how insulin, food, & exercise affect my glucose levels and I’ve learned to adjust the three to maintain a more equal levels of blood glucose throughout the day. It also alerts me when my glucose levels are lower or higher than I want or are falling or rising too fast.

Medicare Prohibits the Use of Available FDA Approved Technology

Before being covered by Medicare, I used the FDA approved Dexcom smart phone app and an FDA approved integrated insulin pump to read the CGM data. Medicare has taken those options away from me and now I can only use the receiver that comes from the CGM manufacturer. In addition to the inconvenience of having to carry and care for another piece of equipment, not being allowed to use smart phone and integrated pump technology can create health hazards for Medicare recipients using a CGM.

By denying access to the CGM data generated by the transmitter to any device except the receiver, the ability to remotely monitor or alternately alarm the person with diabetes is prohibited. This becomes a significant safety issue, such as:

–Caregivers cannot use the Dexcom Follow App, which allows up to 5 people to remotely view CGM data. The Dexcom Follow App can alarm the caregiver when blood glucose levels are out of the accepted safe range so that the caregiver can immediately contact the person with diabetes (or emergency personnel) to prevent severe hyper- or hypoglycemia.

–People with diabetes cannot use the Dexcom G5 Mobile App, which shows real-time data on a smartphone or tablet with the ability to create custom volume alarms and vibrations.

–People with diabetes cannot use a smartwatch to access either app. The smartwatch will vibrate on an individual’s wrist when the blood glucose is outside of a safe range. For individuals who are deaf, hard-of-hearing, or asleep, the haptic (small vibrations on the wearer’s wrist) is needed to ensure that they respond to the alarm.

–Integration of CGM data into insulin pumps is prohibited for people on Medicare, which is currently available for the rest of the diabetes community. As the pathway to hybrid- or closed-loop artificial pancreas technology needs CGM data to be effective, CMS is preventing Medicare beneficiaries from using CGM integrated insulin delivery devices to stay safe.

These restrictions have already caused life threatening situations in real life.  

For example:

Kim H. of Pennsylvania reported to me: “My t1[Type 1 diabetic] husband has a traumatic brain injury. He doesn’t remember how to use the receiver and I must let him keep it at times if I am more than 30 feet from him. He pushes buttons and has entered incorrect bg [blood glucose] numbers making the CGM data incorrect! I need to have control using my iPhone for proper data and effectiveness as I am his 24/7 caregiver.”

Jenny S. of California told me: “I have been legally blind from premature birth & although I can still see I am extremely nearsighted. Seeing a smart phone screen is a whole lot easier than the Dexcom receiver. I already have a phone, so why should I be forced to use a $700 receiver that is very hard to see?”

For me being restricted to using the Dexcom receiver is a real issue when I’m outside. I’m an avid cyclist and triathlete and I’m very hypoglycemic unaware. That means that I cannot feel having low blood glucose levels until the levels approach being dangerously low. Pre-Medicare I used the phone app because it sync’d to my sports watch which vibrated when the app triggered low glucose alerts giving me advanced warning that my blood glucose levels were falling and I needed to eat. The Dexcom receiver is difficult to read in bright daylight and its alarms are not as noticeable when exercising. Since being on Medicare, I’ve been surprised by low glucose levels more than once while cycling. That’s a very dangerous situation because I could lose the ability to control the bike and … well the results wouldn’t be pretty.

CGM’s Can Reduce Overall Costs.

The Economic Cost of Diabetes is Staggering and Growing.

According to the Centers for Disease Control & Prevention, National Diabetes Statistics Report, 2017, (“CDCP Report”) the cost of diabetes care in 2012 was $245 Billion. The American Diabetes Association (“ADA”) estimates the current cost at $322 Billion per year.

Emergency room visits in 2014 included 245,000 cases for hypoglycemia (low blood sugar) and 207,000 visits for hyperglycemia (high blood sugar). That’s almost one-half million emergency room visits for diabetes care. (Source: CDCP Report).

The ADA estimates that 30 million Americans are affected by diabetes, that’s 1 in 11 Americans.

Complications people living with diabetes can suffer include: Stroke, Blindness, Kidney Disease, Heart Disease and Loss of Toes, Feet or Legs.

Use of a Continuous Glucose Monitor (“CGM”) can reduce the onset of complications and reduce overall cost of diabetes care.

The Consensus Statement of the American Academy of Clinical Endocrinologists & the American College of Endocrinology (Vol. 22, Issue 8, August 2016) states:

“CGM improves glycemic control, reduces hypoglycemia and may reduce the overall cost of diabetes management. Expanding CGM coverage and utilization is likely to improve the health outcomes of people with diabetes.”

As reported by the National Institute Health, the report “The Impact of Real-Time Continuous Glucose Monitoring in Patients 65 Years and Older” concluded that “restrictive access to … CGM in the Medicare age population may have deleterious health, economic, and QOL [Quality of Life] consequences.”

HERE’S THE ASK:

Medicare must change its restrictive, dangerous policies regarding the use of CGM’s. It must allow the use of available technology approved by the FDA, including smart phones and watches and integrated insulin pumps. It must cover all CGM’s approved by the FDA, not only the Dexcom G5. It must make the changes NOW.

Feel Good Stories about Medicare CGM Coverage

Although those of us on Medicare are thankful that CMS now covers the Dexcom G5, many online discussions are angry and focused on the frustrating regulation that we are not allowed to use our smartphones, smart watches, and pumps as receivers. I wrote a blogpost about this in August and unfortunately there have been no changes to the policy. In fact the most recent news indicates that legislative action might be required to pull Medicare into the 21st century and mobile health technology.

Today I don’t want to write about gloom and doom. I want to focus on good things and how CGM coverage is improving the lives of many Medicare beneficiaries with diabetes. Without fail D-people are finding the Dexcom G5 to be a life-changing device that helps them monitor blood sugar trends along with receiving warnings of highs and lows. Universally CGM users are learning new things about their diabetes and several have experienced huge improvements in average blood glucose levels and A1c’s. Those who are using a Dexcom CGM for the first time mention a reduction in fear and a new ability to feel “almost normal.”

One thing that I have learned in recent months is that I need to stop saying “seniors” in connection to Medicare. Several people I’ve communicated with about this article are on Medicare due to disability and are not yet 65 years old. At the same time, most of us in the Seniors with sensors (CGM’s) Facebook group are 65+ and have lived with diabetes for a long time.

Here are some stories.

Carol W

Carol W and I are email friends—the digital age version of pen pals. She has had Type 1 diabetes for 55 years since age 5 and qualified for Medicare 12 years ago due to diabetes-related vision loss. For many years Carol has lived in the no-win zone where she needs tight control to manage current and avoid future complications while trying to avoid life-threatening lows. Carol lives alone and in February had a severe overnight hypo resulting in a hit to her head, two black eyes, and severe leg seizures. She doesn’t remember the fall. Her only recourse at that point was to begin setting an alarm for 3 AM to ensure that she was okay. Although Carol and her doctor knew that a CGM would greatly benefit her, she was unable to afford the device without coverage by Medicare.

Fast forward to today. Carol received her Dexcom G5 kit in September. Unable to get training at her diabetes clinic for at least two months, she overcame her fear of the insertion needle and started her first sensor with a Dexcom trainer coaching her over the telephone. Some of Carol’s remarks illustrate the life-changing benefits of CGM coverage.

In Carol W’s words:  “Tiny victory yesterday doing all the things I always need to do and made it through the entire day without any lows/highs or ALL THE TESTING with the meter.   Glorious to feel more “normal” – like the days when I didn’t have to test so often. I paid dearly for those days before tight glucose control though. I lost most of my eyesight…. I was able to go play with my neighbor’s one year old yesterday and didn’t have to think about testing. I just checked the receiver. It is truly amazing! I can go outside and garden and just check the receiver. So happy.”

Nolan

I met Nolan through Facebook and we chat periodically through Messenger. Nolan has had Type 1 diabetes for over 50 years. He has used an insulin pump for 25+ years and a CGM for 8+ years. CGM’s have protected Nolan from severe overnight lows and allowed him to sever his relationship with the local EMS and fire department. Because of the importance of a CGM for his safety, Nolan was self-funding his Dexcom for the last two years. This was stressful for the household finances because he is retired with a limited income.

Nolan has experienced the gamut of Medicare CGM experiences. He was one of the few seniors who received G5 supplies from Liberty Medical in the few months that it was the Medicare supplier. Because of no Medicare reimbursement for the starter kit, Nolan was afraid to use the supplies until October when Liberty assured him that he would not be responsible for the cost. A few weeks later Nolan sounded the alarm that “Big Brother is watching” as he got a call from Dexcom indicating that he was on the list of non-compliant seniors using the G5 mobile app. Although he had been using supplies purchased prior to Medicare coverage and thought that was allowed, Nolan learned that we must delete the G5 app from our phone as soon as our Medicare G5 kit is shipped. Violators were warned that if they were flagged again, Dexcom would no longer provide them with Medicare supplies.

In Nolan words:  “Some of the CMS / Medicare bureaucratic issues are just plain ‘non-sensical’ but it certainly is not the end of the world…. Due to my age, length of time I’ve had T1D I just can’t sense the very low BG situations and my CGM has been simply a Godsend for me and my wife in that regard. Simply put I consider the G5 CGM to be a lifesaver for me.”

Carol G

Diagnosed at age 41, Carol G has lived with Type 1 diabetes for 31 years. She uses multiple daily injections and had never used a sensor prior to Medicare CGM coverage. She knew that she was losing her ability to sense low blood sugars but was uncomfortable with paying out of pocket for a Dexcom.

Carol has been blown away by what she has learned since starting to use a Dexcom G5 in late August. She immediately began to see rollercoaster highs and lows that she had no idea were happening between finger pricks. Although disappointed that the Omnipod is not covered by Medicare, she is seriously looking at pumps as the best way to smooth out her blood sugar. Carol had an unhappy learning experience twelve days after starting her CGM. She accidentally dropped her receiver into the dishwasher where it irreversibly died! Dexcom offered a one-time receiver replacement cost of $200 and after nine very anxious days, she was back to using her G5.

In Carol G’s words:  “My first few days with the G5 were a real eye-opener for me.  I couldn’t believe how many spikes and dives my receiver was showing. And how many alerts I received—at all hours of the night. My mind was going a mile a minute. What changes could I make to stop the alerts, and even-out my “hills and valleys”? I had a long phone conversation with my Dr., but realized that I was mostly in charge of this journey…. I met with my PCP recently—the first appointment since getting the G5…. I was thrilled my A1c had dropped two points since my last appointment.”

Lloyd, Kathy, and Sharon

Lloyd has had Type 2 diabetes for 23 years and I shared his story in an October blogpost. Lloyd has been amazed at the accuracy of his new Dexcom G5 and has identified previously unrecognized lows. He finds that the “load” of managing diabetes seem heavier as a senior.

In Lloyd’s words:  “Decades of experience, great tools, and the load seems heavier to me. I really wasn’t frustrated when you interviewed me, BUT I AM NOW!… I used to be able to manage D in my sleep, now I’d settle for being successful period.”

Kathy is on Medicare due to disability and has lived a nightmare trying to get CGM coverage since Dexcom does not have a contract with her Advantage plan. She is grateful to have access to supplies comped by Dexcom and is looking for a new insurance plan for 2018. Kathy is the poster child for learning a lot about “her diabetes” through CGM use.

In Kathy’s words:  “As a benefit, my bs has dropped from avg 166 down to 127 in 30 days, pretty exciting. The numbers are not as significant to me as the trends: how much to correct highs, dose correctly at the start, toss problem foods, add more protein to each meal. Also a walk uphill drops me 70 points on a straight down double arrow, so its good for me to start a little high.”

Sharon lives with diabetes because of the surgical removal of her pancreas 20 years ago. It took 3 months for her to receive a Dexcom due to the distributor asking for BG logs and doctor notes, then signed logs and signed notes, and finally dated signed logs and dated signed notes. After starting to use a G5, Sharon quickly lowered her A1c from 8.3 to 6.8. She personally is not bothered by the inability to use a smartphone but feels strongly that Medicare beneficiaries deserve access to current technology.

In Sharon’s words:  “But there are people who are reliant on family and friends, although going into a nursing home is not a good alternative, cause they’ll just take away our pumps and cgms and put us on a sliding scale. I hope Medicare will get enlightened about Diabetes so we can get to a closed loop solution. Older people can really benefit from this coverage. It is a life-saver.”

Summary

Medicare coverage of continuous glucose monitoring is not perfect. There are wrinkles and delays in obtaining coverage. The inability to use mobile technology is nonsensical. It is frustrating not to be able to use a Tandem X2 pump as a receiver and to not have access to the Dexcom touchscreen receiver. At the same time CGM coverage is life-changing for Medicare beneficiaries with diabetes. Every person who contributed to this post is living with less fear, more safety, and the ability to live a more normal life. Many people are seeing immediate improvements in their diabetes numbers along with a new understanding of the journey that is “their diabetes”.

Yes, there is work to be done. But we are on the right path.

Tandem t:slim X2 and Dexcom G5:  It takes Flexibility

Last Wednesday I received my email from Tandem with the upgrade code to add Dexcom G5 integration to my pump. A great feature of the t:slim X2 is the ability to perform software updates at home rather than need a hardware replacement every time new capabilities are added to the pump. This first X2 software update adds Dexcom G5 receiver functions to the pump in anticipation of future updates adding threshold suspend and other insulin dosing algorithms. Tandem has a catchy slogan for the X2: “The pump that gets updated, not outdated.”

My Upgrade Experience

I followed the instructions for the upgrade and for the most part, it went well. I had one glitch where an error code indicated that my pump was communicating with another device. I restarted the upgrade and everything went fine. I had not been using my Dexcom receiver and I was assured by other X2 users on Facebook that I could leave the G5 app running on my iPhone and Apple Watch. (Note: the Dexcom G5 transmitter can only communicate with one receiver and one smart device. You cannot use the X2 and the G5 receiver at the same time.)

For the first hour I received an unbroken every-5 minute tracing of my Dexcom readings. After that it went haywire and I got only 2 readings in the next hour. I continued to get multiple Out of Range alerts as the day went on.

When you use a tubed pump, your pump is never far away from your CGM transmitter. My Tandem pump was in a pocket. My Dexcom transmitter was on my arm. My iPhone was on the table, in a pocket, in the kitchen, in my purse and not missing a dot. The pump was struggling with 12 inches.

I called Tandem twice over the next couple of hours and with a little troubleshooting it was apparent that I shouldn’t be having such problems. As always, the Tandem reps were helpful and the second rep indicated that many similar problems had been solved by a new transmitter. My current transmitter has been in use for a month and seemingly fine, but I wasn’t going to argue with trying a new transmitter.

I received the new transmitter on Saturday and will begin using it with my next sensor.

Meanwhile I have begun to get better communication with my Dex sensor, but it is not because the pump is better at picking up the signal. It is because I am making changes. I initially kept my pump in my left front pocket with the sensor on my right arm. I am now wearing the pump clipped to my waistband on the right side. I still lose signal when I sit in my normal “easy chair” and my arm is against the back cushion. (My phone does not lose signal in this scenario.) But I am getting better at moving to the right side of the chair and keeping my arm on the armrest so that the transmitter is not obstructed. I prefer my pump in my pocket, but I can get used to the waistband.

Basically I am being flexible to make things work.

Pump Case

Somehow every change I make impacts something else. Wearing the pump on my waistband has brought back the problem that the clip on the new case is neither tight enough nor long enough to keep the pump secure in the vertical position. Over two days it fell off 5 or 6 times and was saved from hitting the floor only by yanking on my infusion set. Miraculously the infusion set never ripped off. I decided to do a hack of adding a piece of Velcro to the tip of the clip. Bad hack. The Velcro made it difficult to slide the pump onto my waistband. Ultimately I broke the clip off the case by trying to open it wide to pull onto my pants. Definitely user error and because I was given the case for free, I will eventually just order another one.

Second hack. I am back to using a Nite Ize Hip Clip that is attached directly to the pump. When I used this clip a few months back, it also tended to fall off my waistband but not as badly as the Tandem case. This time I put a small piece of Velcro on the pump side of the clip and it hasn’t fallen off once. Of course so far it is only a 3-day experiment.

I am not done yet with figuring out a case hack and think it will involve a Nite Ize clip attached to the Tandem case and a small piece of Velcro. Or maybe just Velcro attached to the case using the Tandem clip. Although the Hip Clip attached directly to the pump is working OK, I prefer the protection of a case. My false occlusion alarms were eliminated by using a case and I am hesitant to go without one. I’ll definitely write another blogpost once I decide on an ultimate fix.

Summary

I like having my G5 information on my pump and I will continue to be as flexible as possible to make it work. Although there is some frustration that my relationship with the X2 is a bit temperamental—first due to occlusion alarms and now to CGM reception—I am still very happy with the pump. In general if I go back and look at the  various pumps and CGMs that I have used since 2005, they have all required me to learn, change, and be flexible to ensure success.

Medicare?

Now I get to the nitty-gritty of this newest update. What are the Medicare repercussions??? I’m flexible, but I can’t say the same thing for Medicare.

I have discussed more than once the stupidity of the Medicare ban on smartphone use for Dexcom G5 users. I’m not going there today. However, I have been hoping that because the Tandem X2 is durable medical equipment (DME) and not a smartphone that I will be able to use it as my CGM receiver instead of the Dexcom receiver.

When I read the Noridian Medicare coding and coverage document released in March, I do not believe that the X2 violates the guidelines:

“Coverage of the CGM system supply allowance is limited to those therapeutic CGM systems where the beneficiary ONLY uses a receiver classified as DME to display glucose data.  If a beneficiary uses a non-DME device (smart phone, tablet, etc.) as the display device, either separately or in combination with a receiver classified as DME, the supply allowance is non-covered by Medicare.”

Unfortunately I have heard from several sources that Dexcom is instructing Medicare customers that current Medicare instructions mandate use of the Dexcom receiver. I suppose justification for that comes from the first sentence of the Noridian document: “The Dexcom G5® Mobile CGM System is currently the only FDA-approved device with a “non-adjunctive” indication.” Although my Tandem pump works with the G5 Mobile CGM System, it is technically not part of the system according to Medicare. Some Tandem pumpers have also been told by Tandem that the X2 is currently not approved by Medicare to be used as a Dexcom G5 receiver.

I continue to be optimistic that Medicare regulations regarding the Dexcom G5 will be changed to allow use of a smartphone and use of the Tandem X2. I have no predictions for a timetable for those changes. In the short run I am still using Dexcom supplies purchased before Medicare and continue to use my iPhone, Apple Watch, and Tandem X2 pump. In the long run I will follow Medicare regulations because CGM coverage is too valuable to risk losing that coverage.

As always with diabetes, I will be flexible.

 

Medicare and CGM Coverage: Swirling Emotions

If you’ve been following the saga of Medicare coverage for the Dexcom G5 CGM, you know that Medicare beneficiaries will be forced to use the Dexcom receiver while being absolutely forbidden from using smartphones and the G5 and Follow apps. Coding and Coverage information released by Noridian Medicare in March 2017 clearly states this Medicare policy:

“Coverage of the CGM system supply allowance is limited to those therapeutic CGM systems where the beneficiary ONLY uses a receiver classified as DME to display glucose data.  If a beneficiary uses a non-DME device (smart phone, tablet, etc.) as the display device, either separately or in combination with a receiver classified as DME, the supply allowance is non-covered by Medicare.”

Few people in the diabetes community think that this makes sense, but for now it is the rule. Most of us on Medicare are grateful for the thousands of dollars we will save annually by having our Dexcom G5’s reimbursed, but emotions are swirling. JOY for coverage. ANGER at the restrictions. ANTICIPATION that sensors will be shipped soon. DISGUST that seniors are being treated differently. FEAR that no longer can our caretakers track our numbers in real time. SADNESS that we are losing access to our phones and watches. TRUST that this policy will change.

Lately I have been waking up in the middle of the night and stewing about being forced to abandon my smartphone and Apple Watch as Dexcom receivers. I worry about whether I will be able to integrate my G5 into my t:slim X2 insulin pump once the the Tandem software is approved. In the light of day I try to sort through my feelings knowing that I shouldn’t lose sleep over this. Mostly I feel frustration because it is a stupid ruling that I have little recourse to challenge. There is sadness because I really like my having CGM number on my watch. There is the sense of loss taking away something that I once had. And not to be ignored is the spoiled-child syndrome that “I want what I want when I want it!” and it’s unfair that others have it and I can’t.

For the most part anger about this situation is not one of my emotions, but others are frustrated, furious, and ready to do battle. A couple of quotes from Facebook:

“This is a ridiculous and ageist policy and I have said it many times. It’s not right.”

“I find it abhorrent that Dexcom G5 is MEANT to be used with smart technology and ANYONE not on MEDICARE has this option.”

“There is no way I can sign that form. It’s aggressive and hostile and incredibly ageist.”

Another emotion I do not have is fear. I currently neither use the Share app nor need someone alerted to my highs and lows. But others are dependent on a caretaker monitoring their BG levels and their safety is jeopardized with the denial of cell phone use.  Some Medicare recipients have disabilities such as low vision that make the larger screens and adaptability features of smartphones a better choice than the small screen of a Dexcom receiver.

“My T1D husband has a traumatic brain injury. So it is invaluable to me, his 24/7 caregiver for 3 1/2 years to be able to use the share/follow app.”

“Share has saved my life a couple of times on the G4 when I was mowing grass and didn’t hear the Dexcom alarm, but I did hear my phone when my wife called.”

“I don’t feel my Lows and my guy gets the alarm on his phone….This is a *safety issue* in my opinion. If we were totally able to feel things and get through without the chance of conking out we wouldn’t even need the darn CGM.”

“I have retinopathy of prematurity and have always had bad vision. Seeing my Dexcom readings on the iPhone is much easier than on a small receiver.”

My Thoughts and Things to Remember:

When my reasonable brain takes control, I know that I will survive using my Dexcom receiver. That is all I had for the first seven years of my nine years using a CGM.

I don’t have medical reasons that my iPhone and Apple Watch are better than my receiver. In fact I prefer dismissing alerts on the receiver because I can just push the button and not even look at the number! BTW that is a bad thing…. On the phone, I need to scan my fingerprint, tap on the alert, and go to the Dex app to dismiss it. I will miss automatic syncing of my G5 numbers to Dexcom Clarity, Tidepool, mySugr, and other apps, but I will survive.

My blog was started in the spring of 2013 and quickly became known for advocacy for Medicare Coverage of CGM’s. If at any point we had been offered the possibility of CGM reimbursement contingent on no smartphone use, we would have jumped at the chance. What we’ve got now is not perfect but it is thousands of dollars per year better than nothing.

Right now I think a lot of my stress comes from just not knowing what is going on. Through the early months of working out the logistics of Medicare, Dexcom did not do a good job of communicating with seniors. Some people were getting email updates. Others of us called Dexcom numerous times to be put on “The List” and never received any information. Seniors are still being told different things by different representatives from Dexcom, DME suppliers, pump companies, and medical professionals. Fortunately there is now some information on the Dexcom website but it does not answer all of my questions. I will definitely have an easier time coping once I know the rules of the game along with hardware and software modifications.

For the most part I am resigned to the Medicare restrictions and am working to accept them. In the short run I think we need to get Medicare reimbursement established before fighting the smartphone ban. Others disagree with me and are making calls, writing letters, starting petitions, and even hiring lawyers. And that is good because although patience is sometimes the best strategy, other times anger and in-your-face advocacy are the only way to force change.

Right now I know that whatever the policy ends up being, I will adapt. I haven’t used a receiver in years, but I’ll get used to it again. I can’t live in fighting mode all of the time and right now need to find acceptance. Although I know that I will eventually take my place on the battlefield fighting Medicare CGM policies, at the moment I am choosing to let things take their course and trust that Dexcom and JDRF will get this changed. At the same time I am cheering on those actively opposing Medicare. One online friend sums up my views perfectly:

“A year or two ago we were all writing letters to our Congressmen to get on board with a bill to have Medicare pay for the Dexcom. Now that is is approved, I’ve decided to let go of any anger and resentment (never does a diabetic good anyway) and am thankful for the approval and the fact that I won’t be paying out of pocket anymore, despite the absurdity of Medicare’s restrictions. However, I will still work in any way I can to change those restrictions if possible.”

Another senior stated it even more succinctly:

“It is what it is. You want Dexcom through Medicare? You sign the form.”

Amen.

 

Note: This blogpost only addresses the smartphone ban for Medicare coverage of the Dexcom G5. There are other problematic policies such as only 2 test strips per day being provided to CGM users. Those issues are in the wait-and-see category and worthy of discussion another time.

Dexcom G5 and Medicare:  What’s Going On?

History

On January 12, 2017, the Centers for Medicare & Medicaid Services (CMS) released a ruling indicating that the Dexcom G5 CGM was a therapeutic medical device and eligible for reimbursement as Durable Medical Equipment (DME). I published a blogpost on 1/15/17 discussing this ruling and I urge you to read it as background for what has been going on (or not going on) in the last six months.

On 6/1/17 Mike Hoskins of Diabetes Mine published an article titled “Stuck Waiting for Medicare CGM Access” and this is good background for connecting the dots from January to June. Yours truly (Laddie Lindahl in Minnesota!!!) was one of the seniors highlighted in the article. Mike summed up the last six months pretty well by writing:

“but so far CMS has not proposed a national coverage policy. As a result, many PWDs on Medicare who previously had coverage or are trying to get CGM coverage are being told they can’t get the devices and supplies they need because “nothing is finalized yet.”

I found the end of the Diabetes Mine article to be quite alarming as Mike suggested:

“Insurance companies send out their contracts to medical supply distributors during the summer months, leading up to open enrollment periods that typically start in the Fall months. So right now is a critical time. Contracts are being crafted and finalized, and with all this Medicare CGM confusion, insurers and third-party distributors may very well simply leave out any language about Dexcom G5 coverage. Effectively, Medicare CGM’ers could face no coverage for their Dexcom supplies for 2018 because so much is up in the air right now.”

I transitioned to Medicare in April anI have been able to continue using my Dexcom CGM due to an extra G4 transmitter saved from my free upgrade to the G5 and from a couple of boxes of stockpiled sensors. Everything I am using is out of warranty, but it works. I am okay….but only for a while. This spring it was announced that Liberty Medical was going to be the authorized Medicare supplier for the Dexcom G5. They were quickly overwhelmed by the demand. (Who knew that it was so complicated?) I placed an order with Liberty and canceled it within a few days of shipping. It had become common knowledge that Liberty was not being reimbursed by Medicare and those of us placing orders might be responsible for the out-of-pocket cost. Meanwhile Liberty withdrew from supplying G5 supplies under Medicare as of 5/28/17.

Where are We Now?

I have had no reliable information source during the last weeks and months, but I have managed to piece together some news. Here is some info with the source and I’ll let you judge the reliability.

Dexcom: Some people on Facebook have mentioned email updates from Dexcom and I have called the company several times and was assured that I was on “The List.” I’ve never received an email. Yesterday I called Dexcom and learned a few new things.

1) Dexcom has set up a Medicare link in their phone menu. Call the Customer Service number at 888-738-3646. Select Option #1 for placing an order. Within that menu, select Option #1 for Medicare Help. Please note that Dexcom is experiencing high call volume about Medicare and I waited almost 10 minutes on hold.

2) If you are desperately out of supplies, call Dexcom and in some cases they are providing supplies.

3) I suggest that you call Dexcom to ensure that your account has the correct insurance information. On Tuesday mine was showing private insurance and Edgepark as my supplier. It has now been corrected to show Medicare as my primary and BCBS as my supplemental.

4) I was told on Tuesday that we each have a “Reorder Specialist” assigned to our account. I found out the name of my specialist and got his contact information. I was told that these specialists are sending out the informational emails and I had not received any because I was not “in his pipeline.”

Facebook: I am in a Facebook group called Seniors with sensors (CGM’s) where members share their experiences and opinions. Of course a lot of the info is “my endo told me” or “the Dexcom email said” or “the letter from Liberty said.”  We all know that the world will collapse into a black hole when Facebook is the source of all knowledge, but here are some things that I have learned:

“I heard from my endo this morning that Dexcom will be doing their own distribution for their Medicare CGM products. No third party like Liberty Medical (thank god.) The hang up at the moment is they are looking for a supplier for meters/strips which Medicare is requiring.” 6/21/17

“Dexcom also told me this week that they will be distributors.” 6/21/17

“I just got off the phone with a very nice Dex Customer Service Rep. Still many unanswered questions from Medicare but she says they expect to be alerting those on the waiting list by end of June” (The rep I spoke with yesterday was unwilling to give me any timetable.) 6/19/17

‘Did you get the email today from Dex with updated requirements from Medicare? They are ” working on it .” Still no way we can use phone / watch combo. I think that ageist and unfair.” 6/15/17

Diabetes Mine: In a 6/15/17 article about the ADA Scientific Sessions, Mike Hoskins and Amy Tenderich shared an update from Dexcom executives:

“If you’re wondering what’s going on with Medicare coverage of Dexcom CGM, here’s the rub: CMS has mandated that Dexcom ship out to Medicare patients “everything they would need” to use the product. Since calibrations with a fingerstick meter are required, that means Dexcom has to find a traditional meter company to partner with to actually ship meters and test strips in the package with their CGM. Kinda crazy, and definitely creating delays for the company and its customers!”

The Part We Hate!

It is becoming increasingly clear that unless things change, Medicare users of the Dexcom G5 will be forbidden from using their smartphones in any form. I understand and previously wrote about the importance of the receiver in allowing the G5 to be designated as DME. The idea that one cannot use a smartphone in conjunction with the receiver is absurd. The dollar value of Medicare reimbursement is significant enough that I can go back to using my receiver, but I hate the idea of abandoning my phone and especially the ability to see my Dexcom numbers on my Apple Watch.

For me it is an inconvenience. But how about those seniors who benefit from someone using the Follow app to monitor their BG trends. How about those seniors who use the accessibility features of their iPhone to access their BG numbers?

It is a stupid requirement. At the same time, my personal feeling is that we need to establish Medicare CGM coverage before we fight this battle. If you read the original CMS ruling, the only reason that the Dexcom G5 qualifies as DME is because of the receiver. If we don’t need the receiver, then unfortunately the G5 is no longer DME. So we need to be careful. That is my 2 cents!!!

What Others Are Saying?

When I began writing this blogpost, I asked my fellow seniors from the Seniors with sensors (CGM’s) Facebook group to share their thoughts. I learned a lot.

“Although it will be a inconvenience for most of us, which will hopefully be temporary, those using the Tandem X2 insulin pump or an Apple Watch series 2 should still be able to connect directly to the Dexcom G5 via Bluetooth by this fall with expected software upgrades from both Apple and Tandem”  —Larry

My T1D husband has a traumatic brain injury. So it is invaluable to me, his 24/7 caregiver for 3 1/2 years to be able to use the share/follow app. He had a severe car accident due to a low blood sugar which the initial 4 months of hospitalizations and rehabilitation cost almost 2 million dollars. If he would have just had a CGM it would have saved all that money, he would still be working and not on disability, and I would still be working. Every diabetic at diagnosis should get a CGM and certainly should not get them taken away at medicare age. He got his after coming out of rehab. We as caregivers near and far need to be able to assist our diabetic family and friends with the features Dexcom has like Share and Follow. —Barry and Kim.

As a type one diabetic who lives alone, it is mandatory to have a CGM that is 100% covered by Medicare. This is a lifesaver. As much as I would hate to be without either my Tandem pump or my Dexcom CGM, my Dexcom is crucial to my daily survival. I will be eligible for Medicare in September, 2017, and I am so very disappointed to find that I will have fewer benefits than I do with private insurance now.  —Cindy

Laddie, my biggest concern is with the exclusion of phones, and especially smart watches from Medicare’s program. In my opinion the use of a Smartwatch to manage Bg and treat T1D is a major advance in T1D care. It is a real time process. No phone need come out of a pocket, no receiver from same or elsewhere. Tap your watch,see your Bg, make treatment decisions in real time. I have been absolutely amazed by this one simple process and the impact it’s had on my life and T1D management. Somehow we must get Medicare to recognize this and allow the use of this technology for treatment. Either that or Dexcom has to build a receiver/watch.  —Dave

I am a Therapist. The watch being important to my work. It is not possible for me to check my blood sugar on a receiver or even a phone at this point during office visits. This restriction on app use is going to cause a problem for me .  —Deidre

Two Medicare people in my household. Repeatedly denied CGM coverage despite multiple appeals and documented Certificates of Medical Necessity the app by my PCP/Endo. Brittle Type 1 46 years with history of severe hypos with seizures and one incident of Nocturnal hypoglycemia leading to coma. One incident of severe DKA requiring 5 days in ICU.  —John

I haven’t experienced a coma yet, but that’s what happens when you have no cgms or no partner to watch over you.  —Dianna

I know, Dianna. Before my CGM I was almost afraid to go to sleep at night.  —Cindy

Signed up for the CGM in January. Now middle of June. Still waiting. Yesterday, another low where I crawled to kitchen for OJ. Made it again. Every time, I wonder when the time will come when I don’t make it.  —Camille

Summary

I think that Camille said it all:  “Yesterday, another low where I crawled to kitchen for OJ. Made it again. Every time, I wonder when the time will come when I don’t make it.”

One Month of Medicare with Type 1 Diabetes

I thought it was going well.

Some of it is great.

I’m learning that maybe not everything is going so great.

I haven’t screamed at a phone menu yet.

I officially started Medicare on April 1. I seem to have figured out how to pay my bills through auto payment. I have received a box of pump supplies and have an order in place for CGM supplies. I have received my insulin at no cost through Medicare Part B and had another prescription covered at no charge through Part D. I belong to a new health club through a program offered by my supplemental insurance. On the surface all of this looks great and some of it is. Unfortunately not everything is going smoothly and Medicare is not approving everything.

What’s Going Great:

Silver&Fit:  This fitness program is a benefit of my BCBS Supplemental policy. It provides a membership at a participating fitness facility, an instructor-led class, or access to Home Fitness kits. I joined a club five minutes from home that has a huge number of work-out machines, weights, a spa, nutrition and fitness programs, locker rooms, and free fitness classes. I have been attending numerous strength and cardio classes and having a great time. No charge at all. My only limitation is that I can only use the club I joined and not the other branches around Minneapolis. I literally walked in the door and was a member 10 minutes later.

Doctor Visits: In April I had two routine doctor appointments. It was easy to provide my Medicare information and as far as I can see, they are being covered with no issues. I feel bad seeing how low the Medicare reimbursement is for my doctors.

Not Perfect but On the Right Track:

Insulin for Pump: As I explained in a previous Medicare blogpost, insulin for an insulin pump is covered under Part B DME. With my supplemental plan coverage that means I get my insulin at no cost. I am not bound by formulary restrictions nor does my insulin require a copay or put me into the Part D donut hole. The new prescription from my endocrinologist contained the required information and I spoke to a pharmacy tech to remind them to file it with Part B. Very quickly I got an email that the prescription was ready; it had been charged to my Part D plan with a charge of $481 for 3 vials.

The next morning I went to Walgreens and fortunately the pharmacist on duty knew how to correct the problem. She told me that it would be referred to the central Walgreens Medicare department and it might take 2 days to set up. That afternoon I got a call from the Medicare department and was asked for information such as my pump brand, model, serial number, purchase date, and whether it was paid for by Medicare or private insurance. That all made sense and was easy to provide. She finished our conversation with two questions. How tall are you? What do you weigh? Huh??? She said that my insulin would be ready for pick-up in an hour and it was.

Pump Supplies: In March I contacted Tandem Diabetes to learn my Medicare supplier for pump supplies. I was told that according to my supplemental insurance, I should use CCS Medical and Tandem would set up the account for me. CCS has been great so far and has contacted me and my endo’s office several times to get the necessary information. One requirement was a C-Peptide test which I had never had before in my diabetes career. As expected, I passed or failed the test depending on your criteria. I failed because I produce minimal to no insulin. I passed because I qualify for a pump and supplies under Medicare.

My pump supplies arrived quickly and were exactly as ordered. Last evening I went into the Medicare site to check my claims and was stunned to see that my pump supplies were denied. I called Medicare this morning and got no good answers as to why. It was suggested that maybe I was using the wrong supplier and I was given the name of another supplier who doesn’t even provide supplies for insulin pumps. I called CCS and the rep indicated that they were already working with Medicare to get it straightened out. She said that it was very common for supplies to be denied on the first go-round for patients new to Medicare. She assured me that everything is OK and I am choosing to believe her.

A Total Mess:

All of us on Medicare were thrilled when the Centers for Medicare and Medicaid Services (CMS) announced in January 2017 that the Dexcom G5 was now covered as a therapeutic CGM under Medicare DME. Soon after that CMS released a document with preliminary coverage criteria and Liberty Medical was identified as the sole Medicare-approved supplier for the G5. Liberty was deluged with calls but managed to start shipping supplies to some customers. One caveat however. In order to receive supplies, you had to sign that you would be responsible for the cost of the supplies if you were not approved by Medicare. Meanwhile it was announced that more specific coverage criteria were still to be released and Medicare was not approving orders filled by Liberty.

Last week it became apparent that Liberty is not going to continue to supply G5 supplies for Medicare beneficiaries. All along Dexcom has indicated that it will not (cannot?) sell G5 supplies out-of-pocket to people covered by Medicare. Please note that the cash price from Liberty is much higher than the previous cash prices from Dexcom. Dexcom will sell G4 supplies to Medicare beneficiaries out-of-pocket. On Monday I received a letter from Liberty officially indicating that they are not going to provide Dexcom supplies after May 28. At this time there is no other supplier.

I placed an order at Liberty about a month ago. I was called last week to indicate that they had everything required to process my order and that it was under medical review. Today I canceled the order because I do not want to be stuck with the responsibility of getting an initial denial by Medicare, having to pay cash for the order, and then filing an appeal. I think I’ll wait to see what happens in coming weeks or months.

Dexcom has been quiet and provided little help to seniors. Today some people received a form letter from Dexcom indicating that they are working on the problem and stating: “If you have an immediate, critical need for Dexcom G5 Mobile CGM supplies, please contact Dexcom at 888-738-3646.” I did not receive the email.

So currently the Dexcom G5 is covered by Medicare, but not really. I am choosing to be patient and optimistic that everything will be worked out soon. Many other seniors on Facebook are angry and less optimistic.

Summary:

Some of my diabetes needs are being met through Medicare and other things are being worked out. So far I have had no problem reaching customer service reps at Medicare, CCS Medical, Walgreens, Dexcom and Liberty. Everyone has been polite and helpful to the best of their ability. Unfortunately no one at Dexcom or Liberty really seems to know what is going on and I believe them when they say the delay is with CMS. The Medicare Help Line was answered promptly but they could give me no reason for my supply denial and then nicely gave me inaccurate information. CCS Medical has been very responsive and so has Walgreens.

Right now I have everything that I need, but that won’t be true for the longterm. In the past I have often had problems when switching insurance plans and suppliers. I am hopeful that most of my Medicare problems are in the same category. I expect the pump supply problem to be resolved fairly quickly. I am less optimistic about CGM coverage.

So that’s today’s story about Medicare and Type 1 diabetes. Stay tuned for more. 😀

 

Countdown to Medicare with Type 1 Diabetes:  1 Month / Growing Old with T1D

Laddie_Head SquareI don’t have much to write about this month when it comes to Medicare. I am signed up for Medicare Part A and Part B. I have enrolled in a Supplemental Plan offered by BCBS of MN. I have selected an AARP Walgreen’s Part D drug plan. For better or worse I am ready to tackle Medicare on April 1.

Turning 65 years old and going on Medicare is a milestone in the progression of growing old. It is impossible for me to make this transition without thinking about growing old with Type 1 diabetes. Below you’ll find some of my thoughts.

The idea of “phases of aging” makes sense to me and I am moving into the “young-old” subgroup described in a Lumen Learning sociology course:

The United States’ older adult population can be divided into three life-stage subgroups: the young-old (approximately 65–74), the middle-old (ages 75–84), and the old-old (over age 85). Today’s young-old age group is generally happier, healthier, and financially better off than the young-old of previous generations.

As a young-old person who has lived with Type 1 diabetes for over 40 years, I am the most confident and empowered in relation to my diabetes than I have ever been. That is not going to change on April 1.

When I was diagnosed in 1976, I knew nothing about diabetes and had access to only a few books and magazines. Today the Internet has opened doors to scientific knowledge, professional recommendations, advocacy issues, and the cumulative knowledge of thecountdown-to-medicare-1-month Diabetes Online Community (DOC). Although I don’t blindly follow online diabetes advice and have never consumed okra water, I strongly believe that my fellow people with diabetes (PWD) have taught me almost everything I know about Type 1 and have motivated and empowered me to succeed. Continued learning about diabetes won’t go away just because I get a Medicare card.

I have lived a privileged diabetes life and have never worried about access to care. I understand that I will have a huge learning curve when it comes to getting supplies and medications under Medicare. I am not yet losing sleep over potential roadblocks although I know that it is naive to think that there won’t be any.

There is no doubt that improvements in both insulin formulations and technology have allowed me to reach age 65 in reasonably good health. I can’t envision what my health status would be (or if I would even still be alive) had I continued on my 1976 insulin regimen of one injection a day and no home BG monitoring. Insulin pumps and CGMs have exponentially increased the quality of my life. I can’t even begin to hypothesize on how and if Medicare will cover future diabetes tech such as artificial pancreas systems.

In some ways I am living with a different diabetes than at other stages of my life. Although hormones never completely disappear, they don’t rage as much for me anymore and are usually more predictable than when I was younger. In Figure 5-2 of Think Like a Pancreas, Gary Scheiner shows graphs of “typical basal insulin levels by age group.”

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The thick line is for ages 60 and older and shows a decrease in total basal insulin along with a sharper rise in insulin needs in the early morning hours. I am experiencing both of those changes and they didn’t make sense to me until I saw Gary’s chart. Most of my bolus ratios have remained the same so far.

Hypoglycemia unawareness is a mixed gift bag as I move into my senior years. On one hand, I feel better because I don’t get the sweats, shakiness, blurry vision, and insatiable hunger of my younger years. I also don’t tend to over-treat lows and multiple bowls of Frosted Flakes at 3:00am are a distant memory. At the same time I know that hypoglycemia is a huge problem for seniors with diabetes and my risks for falls, hospitalization, and permanent disability resulting from severe lows will increase. Knowing that Medicare will soon be covering CGMs for seniors is a huge relief, but I won’t consider it a done deal until I am approved under the not-yet-established CMS guidelines.

When I look at my diabetes, I am comfortable believing that I will be in control of my diabetes throughout my “young-old” years and hopefully well into my “middle-old” years. It is likely that I may require help with care at some point in my “old-old” years…. That terrifies me because I don’t trust anyone else to take care of my diabetes and my biggest fear of aging is losing independence.

Aging is a process. My life isn’t going to be much different on April 1 than it was on March 31. I’ll still have type 1 diabetes and will continue to test my blood and take insulin. I’ll still have arthritis and sometimes I worry more about that than diabetes. But one change that will happen is that I will finally start using the red, white, and blue Medicare card stashed in my wallet. Wish me luck.