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