What happened after Blue Cross rejected her daughter Laura's application for a continuous glucose monitor? Gillian Miller took on the big boys and won!

Laura Miller and her mother challenged their insurer and won! They got the continuous monitor they needed.

Mar 27, 2008

Fifteen-year-old Californian Laura Miller, a brittle diabetic, and her mother, Gillian, thought they had a strong case when they asked Blue Cross in late 2007 to pay for a continuous glucose monitor for her.

But when the health plan denied their application, hope turned to near despair, and then anger. The Millers began an almost three-month odyssey that took them from being optimistic petitioners to shocked rejects to gratified recipients of help from an agency more Californians with diabetes should be aware of.

The Letter That Started It All:


November, 2007

Dear Blue Cross:

My name is Laura Miller. I am a 15-year-old 10th grader. I am a singer and a performer and a very hard worker. I am also a type 1 diabetic.

I am nearing 6 years of this disease, but it seems like much longer. Why? Because every second of my life I must worry about my blood sugars, which have been extremely out of control for the past five years. Even though I keep a very strict record of blood sugar testing, 10-12 times a day, my numbers can range from 40 to over 600 in the space of 3 hours.

This severely affects the way I function in my life. Always, for example, as a top student in my school, I find it hard to finish the massive amounts of work I am required to complete every day when my blood sugar numbers are completely out of control.

I must stay awake all night long checking my blood sugars every hour to make sure they are coming down. Often, I don’t get the work done because my high or low blood sugars don’t allow me to stay in focus or feel well.

I am a member of the National Choir, and the daylong rehearsals do not allow me time to stop and check my blood sugars as often as needed. On my rehearsal days I get an average of 2 blood sugar tests a day. By the time the day has gone by and I don’t realize that my blood sugars have been off the charts all day, I am forced to stay up all night to get them back down, and the cycle repeats itself.

I check my blood sugars before performances, but that is not enough. I need something that can monitor my blood sugars continuously, so I can be in control of my life and my future.

What scares me most is what these high blood sugars are doing to me. Every time my blood sugars go high I am reminded again that if this keeps up my eyes, legs, kidneys and my life are likely to be gone before I hit 40.

When my friends talk about what they want to be when they grow up, who they want to marry, and how many kids they are going to have, I watch and listen to their dreams, all the while thinking how lucky they are not to have to sink lower and lower into a whirlpool of out-of-control blood sugars and the long-term, but not so far away, effects of this disease.

What wouldn’t I give to be one of them, to get up in the morning and feel refreshed from a good night’s sleep or to be able to get up and engage myself in activity without frequently stopping to check my blood sugars. I would give anything.

The trouble is, I can’t. I NEED something to help me out of this horrible mess so I can live my life to the fullest and not as a medical disaster or as a huge medical expense to Blue Cross.

I am asking for your help, and you are the one who can change my life forever and ever.

Laura Miller

Age 15


Gillian Miller accompanied her daughter’s letter with a plea of her own, telling Blue Cross that, “I am a very tired mother of a type 1 diabetic.” She told of pressures on her not only from assisting her daughter, but also from having to tend other family members, including an incapacitated husband, a sister recovering from a double mastectomy and a father afflicted with Parkinson’s.

Not to Be Denied

Blue Cross was not moved. It denied the CGM for Laura, stating that a monitor was an “investigational” device, good for limited diagnostic use but not indicated for everyday therapy.

Angry, Gillian Miller fired off a letter to the doctor who had denied the application, telling him that, “It is very easy for you to sit in your office and say NO,” and “The continuous blood glucose monitor is a lifeline for her. How can you be so narrow as to deny a young girl a full life?”

Miller, the owner of Diabetes and More, an online diabetes supplies and accessories store, did not let the matter rest there. She contacted the HMO Help Center at Department of Managed Health Care (DMHC), a department of the State of California’s Business, Transportation and Housing Agency.

The Sacramento-based DMHC turned her plea over to the Center for Health Dispute Resolution (CHDR), an independent medical review group. CHDR, which is funded partly by the state, receives compensation regardless of whether it upholds or overturns a health plan’s decision to deny services.

The Independent Panel Checks In

A CHDR panel of three practicing doctors reviewed the Millers’ application. On February 12, 2008, it wrote to Gillian Miller: “The Center for Health Dispute Resolution has determined that the requested equipment is likely to be more beneficial for evaluation of the enrollee’s medical condition than any standard therapy. Therefore, CHDR has decided that Blue Cross of California’s denial of the requested equipment should be overturned.”

Perhaps the sweetest part of the CHDR letter for the Millers was the section addressed to Blue Cross: “You cannot appeal this decision. The Department of Managed Health Care does not accept appeals of a CHDR decision. The decision of CHDR is final.”

The next day, February 13, Gillian Miller received an acknowledgement from Blue Cross’s legal department: “Pursuant to the DMHC’s recommendation, Blue Cross is reversing its previous denial and authorizing the continuous glucose monitoring system. This authorization is in accordance with your Individual PPO benefits and claim will be paid accordingly, including all applicable deductibles and co-payments.”
Postscript

Frustrated at Blue Cross’s rejection of her daughter’s request for a CGM, Gillian Miller went ahead and paid for a monitor out of her own pocket last December. The state’s subsequent decision to overturn the denial means that Blue Cross will reimburse Miller for the monitor.

She reports that since mid-December her daughter has welcomed the freedom her CGM has given her. Laura only has to calibrate the monitor twice daily compared to her previous practice of checking her blood glucose levels up to 12 times a day.

Contact information for the California Department of Managed Health Care:

980 Ninth St., Suite 500
Sacramento, CA 95814-2725
(916) 255-0904
(916) 255-2490 fax
www.hmohelp.ca.gov

Click Here To View Or Post Comments

Categories: Blood Glucose, Blood Sugar, CGMs, Diabetes, Diabetes, Health Insurance, Heroes, Inspiration, Meters, Type 1 Issues


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Comments

Posted by Anonymous on 26 March 2008

Now if Medicare would consider this as a covered expense, my life would also improve.

Posted by Anonymous on 3 April 2008

Also, check out cgmscentral.com for more reimbursement information, and to share how you got reimbursed with other folks!

Posted by mgordon on 6 April 2008

Diplomatic Fighting words do work. But why should one have to go thru that? Great work Laura and Gillian!

Posted by Anonymous on 7 April 2008

The change needs to come from the FDA. My understanding is that they have not approved continuous glucose monitors for diabetes management. If the FDA would approve these devices for managment then insurance companies would have no excuses (not that they need one but it helps to have FDA approval.)

Posted by Anonymous on 10 April 2008

We are also fighting with Blue Cross to get the CGM covered for our daughter Laura that is 21 years old and Down Syndrome. Laura rarely recognized when she is hypoglycemic so you would think trips to the ER would counter the cost of their denial. Laura doesn't understand the BG numbers tha well but hearing an alarm alerts her. We are appealing the denial

Posted by Anonymous on 11 April 2008

Great work Laura and Gillian. For me it had to take me getting into a big car accident from my low glucose before they approved my coverage.If i had seriously injured someone else or myself they would have to have paid much much more out in expenses.

Posted by Anonymous on 11 April 2008

We had to go though the same thing with United Health Care. We sort of won. We had to pay for half the cost of the monitor, and meet a $500.00 deductable on the sensors.
Personally I think the that problem is with the health care system all together. If all the places that make the medication and medical equipment we need where non-profit then the cost would not be as high and we could all possible afford it.

Posted by Anonymous on 21 April 2008

I read the letter that Laura Miller wrote and was horrified. She is so misinformed about her own disease that she doesn't sleep, and is worried about being blind or limbless by the time she is forty. I've been diabetic nearly all of my forty-three years and never once was I told by any of my Dr's or CDE's that I would have such consequences. I seriously think that she needs to speak to a good educator and a psychologist to get her irrational fears under control. As for her mother, she needs to realise that the CGMS technology is still in it's infancy and to realise that the insurers are not going to cover it until it gets proper approvals. Otherwise she should do what I do and pay for it out of pocket until it is covered.

Posted by Anonymous on 30 April 2008

To whoever wrote the comment that said Laura Miller was misinformed about her disease, I have one question. Are you really a type 1 diabetic? I cannot imagine someone who has diabetes for 43 years making these comments to a young girl struggling with her disease.
Good luck, Laura.

Posted by Anonymous on 5 May 2008

Good for you Laura and Gillian! Way to fight for what you need. Congratulations!!

Posted by Anonymous on 10 May 2008

" If all the places that make the medication and medical equipment we need where non-profit then the cost would not be as high and we could all possible afford it."
If this was true the medication and medical equipment we need wouldn't exist!

Posted by Anonymous on 15 June 2008

I agree with the statement re: who wrote the comment on Laura Millers disease . The person who wrote that cannot be type 1. My grandson is and the future effects of this disease is as she states. It can be read anywhere. It is very hard to control a young persons blood sugars! I worry all the time that Nick may have to deal with these symptoms later. I know of someone who is dealing with blindness, kidney failure etc., as a result of diabetes. As soon as we are eligible, I am going to apply for one for Nick. I hope its not a battle then for somethins SO HELPFUL in maintining blood sugars!

Posted by young diabetic on 7 July 2008

I think I know someone who is a little more misinformed... I am 23 years old, and have been a diabetic for 10 years. I JUST left the hospital at 3:30 this morning due to none other than diabetic neuropothy. My legs feel like they have ants crawling all over them. All I can say is they CAN happen... Kudos to her though for trying so hard to PREVENT those VERY REAL diabetic side effects. Perhaps you have a personal Endo on call 24-7 since birth to watch over you?? --Walk in the shoes of a brittle diabetic before speaking next time... or "do some research"

Posted by Anonymous on 1 August 2008

To "young diabetic", I am the person that posted on April 30th and asked the previous poster if they were really a type 1 diabetic because of the comments they made. I have been diabetic 45 years, also being diagnosed at the age of 13. I just wanted to say to you (and Laura Miller), just stay positive. When I get discouraged about my disease, I just try to remember that there are worse things than diabetes. I try to remember that diabetes is just one of life challenges I have been dealt, and hopefully, it will make me a stronger person.
GOOD LUCK!

Posted by Anonymous on 17 September 2008

WOW! I read the story as well as all the posts, and when I came across the negative post, you know who you are, I felt a pain and a sorrow like I have never felt before.

I remember what I went through when I was nine, waking up from a coma, and listening to a doctor tell me why I was so different from other people. I am 29 today, and still suffer from depression because of how my life turned out.

Laura, family, and those that can relate, please stay strong in the face of uncertinty. There is hope that in your lifetime, we will have a cure. I know that people make comments about your "pager," because they believe that to be old technology. Tell them it's an insulin pump and continue your day.

I fight with my sprituality every day, I feel like, because of no family history, that it shouldn't have happened to me. Laura, you were given this illness because you and you family are super strong, and have initiated a CHANGE in the way that other type 1's think about their options when it comes to corrupt insurance companies.

I pray that you stay healthy and move on to become something great in this troubled USA.

Sincerely,

Kevin Selva


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