Dr. John S. Yao, M.D., M.P.H., F.A.C.P, the Staff VP Medical Policy Development, Office of Medical Policy & Technology Assessment stated in an email:
Anthem’s position regarding coverage for insulin pumps has not changed per CG-DME-01 and there have been no changes to our members’ access to insulin pumps based upon that document. However, Anthem has adopted CG-DME-38, which is a new guideline that considers the use of continuous interstitial glucose monitoring (CIGM) devices by individuals with type 1 diabetes as Medically Necessary when criteria have been met. For individuals with type 2 diabetes, the use of CIGM is considered Not Medically Necessary. Anthem members with type 2 diabetes who are already receiving care with CIGM will continue to have coverage for their CIGM devices and supplies.
Disturbing News For Type 2 Diabetes Anthem Members
For individuals with Type 2 diabetes who are prescribed insulin or insulin pump therapy for diabetes management, this policy guideline is disconcerting, as the Type 2 diabetes community grows each day and more individuals are being prescribed insulin.
Anthem Insulin Pump Coverage
If you are wondering how the decision to provide insulin pump coverage is made at Anthem, this is what Dr. Yao has to say:
Please be aware that decisions of medical necessity regarding insulin pumps are made by Anthem’s Medical Policy and Technology Assessment Committee (MPATC). MPTAC consists of physicians external to Anthem who are in active academic and community practice, as well as internal Anthem medical directors. Anthem clinical guidelines are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, national physician specialty society recommendations, and the views of medical practitioners in relevant clinical areas, and any other relevant factors. The available published medical evidence is reviewed regularly and monitored for new studies and data regarding the safety and efficacy of a wider variety of medical therapies, including insulin pump devices.
Future Anthem CGM Coverage
And in relation to Continuous Glucose Monitoring (CGM) coverage, Dr. Yao states:
In developing our position on CIGM devices, the MPTAC carefully reviewed and discussed the available scientific studies as well as the recommendations from the American Diabetes Association (ADA), American Association of Clinical Endocrinologists (AACE), the American College of Endocrinology (ACE), and the Endocrine Society. Our current position is generally consistent with the recommendations from the ADA. The opinions and recommendations of “device salespeople and formulary purchasing agents” play no role and have no influence in the MPTAC decision-making process.
Earlier this year, DPAC participated in the AACE/ACE Consensus Conference for Continuous Glucose Monitoring. The summary statement is here. Those in attendance included patients and organizations, but the majority were the top endocrinologists in diabetes care. What was the consensus? The short answer is this:
…real-time glucose monitoring should be available to ALL insulin-using patients regardless of type.
They are a top “authoritative organization,” so we hope that Anthem will include this statement in their analytical review of medical evidence. If they need studies, that statement alone includes 68 scientific studies that confirm the overarching need for CGM device coverage to anyone taking insulin.
What You Can Do Right Now
If you think that one email won’t make a difference, here is the takeaway… it can. Because this is how Dr. Yao ends this email:
We are pleased to let you know that a full review of the medical evidence and updated recommendations from authoritative organizations regarding this issue is currently underway. The resulting analysis will be presented to the MPTAC at our upcoming 3rd quarter meeting. The outcome of MPTAC’s review of this topic will be made available later this year in the form of an updated policy document on our publicly accessible websites. Please follow the instructions below to view those sites.
– To enter site, click a state – for example, <Indiana> <Enter>
– Scroll down and click on <Anthem Medical Policies and Clinical UM Guidelines.
We look forward to reading the updated Anthem policy document. We would like to see more responses, which involves our community taking action: a few clicks to send emails. It’s easy, like most DPAC actions, but it does make a difference.