My name is Laura Siner and live in Columbia, MD. I was diagnosed with type 1 diabetes
in June 1970 age 23. At that time the only tools available to people with type 1 diabetes were
insulin, a very strict diet and exercise. The average life expectancy for someone with type 1 was
45—if you were lucky.
Over the years I’ve had many close calls, and it’s a little short of miraculous that I’m
relatively healthy. I volunteered for many studies to try to find something that would control my
diabetes. I tried the U100 insulin, the first blood glucose meters, and the earliest insulin pumps. I
even was in a study 15 years ago for an internal insulin pump. When it worked it was great, but it
was not ready for prime time—in fact it nearly killed me.
I wasn’t able to control my blood sugar until I went on the CGM in 2010. Our private
insurance paid 100 percent of the costs so when I went on Medicare in 2013 I was shocked when
Medicare refused to cover it.
I know that the CGM is the best chance type 1s have of avoiding the complications that
arise from uncontrolled blood sugar levels. It is truly life-saving and certainly worth fighting for
so we decided to appeal
It took three years and four appeals but on August 13, 2015, We were notified by the
Medicare Appeals Council (MAC). That we had won and that Medicare would cover my CGM.
Further it would reimburse my out-of-pocket costs for CGM supplies I bought before the
successful outcome of my appeal.
So what does my success mean for other people with diabetes who are on Medicare, who
should have CGMs (according to diabetes experts, this means almost all type 1s) and who have
been refused coverage?
Most obvious—while there are no guarantees, an appeal can be successful. But the
appeals process is long an frustrating and to be successful you must carry it through to the end.
You start the process by asking for coverage for your CGM. You need to have a CGM before
you start so you have something to appeal.
I found out that my CGM wasn’t covered from the Medicare Summary Notice for Part B.
which Medicare sends out regularly to recipients. On the first page of the notice you will see the
number of items denied and the total you may be billed.
On the last page of the notice is a form for filing an appeal with instructions and phone
numbers to call if you have questions. I have always found the Medicare folk very helpful in
answering questions. Make sure you follow the instructions to the letter and that you file the
appeal by the date listed on the form.
This appeal has an almost 100 percent chance of being rejected. I filed my appeal in
April and got the rejection in October of 2013. The rejection notice contains a form and
instructions for 2filing a reconsideration of the appeal.
The reconsideration also has almost no chance of success but it must be filed to continue
the process. The papers we filed for the reconsideration were almost identical to those we filed
for the original appeal. With the expected rejection of the reconsideration came a form to
request a hearing before an administrative law judge (ALJ).
The ALJ hearing is the first chance you get to make your case in person to another human
being and is your best chance for success. You are allowed to name some one to represent you at
the hearing and I chose the best, my doctor Nicholas Argento. The hearing was held by telephone
on March 4, 2015 and on March 6 Judge Donna Dickens ruled in my favor.
However, it was not over yet. I was told the Medicare would almost certainly appeal the
ALJ decision to the Medicare Appeals Council (MAC). And while the hearing before the ALJ
concerns medical matters but the hearing before the MAC concerns matters of law and for that
you need a lawyer familiar with Medicare law and legal procedure. Again we got the best,
Debbie Parrish. She told us that Medicare had 60 days to file an appeal and that they would
invariably wait until the last day to file. So it went. Debbie immediately file a response but in the
end the MAC refused to hear the appeal and on August 13, 2015, we were notified that Judge
Dickens decision was final and that Medicare must cover my CGM.
If you have any questions on want more details I would be happy to help. My email
address is:
[email protected]