What is Diabetes?
Diabetes is a long-term health condition affecting the way your body turns food into energy. The body breaks down most foods into glucose, then releases that glucose into the bloodstream. As your blood sugar increases, the pancreas releases insulin which tells your body how to use the blood sugar for energy. Those with diabetes do not make sufficient insulin or are unable to use the insulin correctly. Over time, this can lead to kidney disease, loss of vision, heart disease, and other serious health problems.
According to the Centers for Disease Control and Prevention (CDC), more than 37 million adults in the United States have diabetes—and one in five are unaware they have the disease. Diabetes is the seventh-leading cause of death across the United States, and the top cause of kidney failure, adult blindness, and lower-limb amputations. Over the past two decades, the number of adults diagnosed with diabetes has more than doubled. There are three primary types of diabetes:
- Type 1 Diabetes is believed to be an autoimmune reaction that prevents the body from producing insulin. About 5-10 percent of those with diabetes have Type 1 Diabetes, which is usually diagnosed early, as a child or teen. Type 1 diabetics require insulin injections every day to survive.
- Type 2 Diabetes causes the body to be unable to keep blood sugar at consistent levels because insulin is not being used correctly by the body. Type 2 Diabetes develops over a period of years and is more typically diagnosed in adulthood.
- Gestational Diabetes develops in pregnant women, placing their baby at a higher risk of health problems and increasing the likelihood that the mother will develop Type 2 diabetes later on.
What Are Some of the Most Common Diabetes Treatments?
Type 1 Diabetes is always treated with insulin and could also potentially be treated with a pancreas transplant or islet cell transplant. There are more than 20 types of insulin currently marketed in the United States including:
- Short-acting insulins like Humulin R U-100, or Novolin R ReliOn
- Rapid-acting insulins like inhaled Afrezza, Fiasp, FlexTouch, Apidra, Admelog, and Lyumjev
- Immediate-acting insulins like Novolin N
- Long-acting insulins (lasts up to 24 hours) like Tresiba, Levemir, Lantus, Basaglar, and Toujeo
Amylinomimetic injectables that work by delaying the time your stomach takes to empty and reducing the hormone glucagon after meals may also be used for Type 1 Diabetes.
Type 2 Diabetes may require treatment with oral medicines for years but could eventually require insulin and other Type 1 treatments to maintain control of glucose. Since Type 2 Diabetes can be progressive, multiple medications could be prescribed over time. Metformin is usually the first step in treating Type 2 Diabetes for those who are unable to make the necessary lifestyle changes that could reverse the disease—or for those who have made changes but need additional help. If metformin is not working, SGLT2 inhibitors (Invokana, Farxiga, Jardiance, Steglatro), DPP-4 inhibitors (Januvia, Janumet, Onglyza, Glyxambi), and GLP-1 receptor agonists (Trulicity, Byetta, Ozempic, Victoza, Saxenda) may be combined with metformin or taken on their own.
Many doctors also recommend glucose meters and monitors to their patients so they can measure the amount of sugar in their blood. These are classified as durable medical equipment (DME) and include brands like Freestyle Libre, Dexcom G6, Eversense, and Guardian Connect System.
Are Diabetes Treatments Medically Necessary—and Could They Be Denied?
Type 1 diabetics require insulin to live, so it is medically necessary. If you have insurance, it will typically pay for most insulins, with your co-pay being around $35 per month. Medications for Type 2 diabetics may be medically necessary, but insurance companies may be reluctant to pay for the newer drugs, preferring to pay for metformin which is not nearly as expensive as many other drugs.
For instance, Jardiance costs about $750 for a month’s supply. Glyxambi is about $550 per month, and Trulicity and Ozempic are more expensive, at around $1,000-$1,200 per month. This means that your insurance company may require you to start with metformin, then move to an SGLT2 inhibitor or DPP-4 inhibitor before they will pay for the newer GLP-1 receptor drugs.
What Should You Do if You Receive a Diabetes Treatment Insurance Denial?
If you’ve received a diabetes treatment insurance denial, your doctor may be able to re-submit your claim along with a letter stating the drug is medically necessary for your diabetes. If this does not cause the insurer to reverse the denial, you may need to file an appeal. You will first file an internal appeal, according to the guidelines of your plan. If this appeal is not successful, you will file a third-party external appeal.
When you are dealing with a job, school, children, and everything else life brings, appealing an adverse insurance decision can seem overwhelming. Attorney Scott Glovsky is ready to step in and fight your insurance company on your behalf to get the drugs you need for your diabetes. While any insurer may deny a diabetes treatment, some of those companies could include Anthem Blue Cross, Blue Shield, Health Net, Kaiser, UnitedHealthcare, Aetna, or others.
How Attorney Scott Glovsky Can Help When Your Insurance Company Won’t Approve Your Diabetes Medication
When your insurance company won’t approve diabetes medication, you may feel frustrated and overwhelmed. The consequences of a diabetes medication denial can go from merely inconvenient to catastrophic. When you’ve spent years paying health insurance premiums only to have your claim denied, it can be extremely discouraging as well as damaging to your health.
The Law Offices of Scott Glovsky is waiting to help you through this difficult time by ensuring your insurer holds up its end of the bargain. Attorney Scott Glovsky and his legal team know every tactic practiced by insurance companies and know how to effectively counteract these tactics. Contact the Law Offices of Scott Glovsky today.