Thread by @KellyRawlings

Health plan, you may think you’re saving $ by putting quantity limit on my test strips—less than my dr has prescribed for my basal-bolus insulin therapy. My rebel force—including pharmacist, nurse, and doctor—is going all out on this. Quantity over-ride faxes and calls incoming.

Annddd... insurance plan has indicated quantity over-ride for strips is in review. For 72 hours. Meanwhile, my blood glucose is doing its unlevel best and my exogenous insulin is insulining.

I loved that my nurse cheered me on to call the health plan. She, too, is tired of plans putting stingers, hurdles, blockades, fences, etc., in the path of patients and their doctor-prescribed therapies.

Hey, insurance plan, you may not be aware that the @AmDiabetesAssn, in the Standards of Medical Care for Diabetes—2019, has the following to say about self-monitoring of blood glucose for those on intensive insulin therapy...

Now, there are some clinical terms in those clinical recommendations. I shall translate.

Most patients ... that means people like me. Or you, for that matter.

using intensive insulin regimens ... that means we use exogenous insulin multiple times every day, in very specific ways, as medicine.

multiple daily injections or an insulin pump ... multiple means more than 1 daily. Injections mean sticking a syringe or pen needled into the skin surface and into the tissue just beneath and squirting in insulin. The amount of insulin varies. More on that soon.

insulin pump therapy ... amazing technology! This device squirts the insulin into the tissue for us, via an infusion set that keeps a metal needle or flexible cannula in our tissue for 2-3 days. Sometimes we tell the pump how much to squirt. Sometimes it lets our brains rest...

...and does the squirting for us, based on a tiny little computer that we told, in advance, how much to squirt.

should assess glucose levels using self-monitoring of blood glucose (or continuous glucose monitoring) ... this means we should use a test strip, a drop of our ow blood blood squeezed from a clean fingertip, and a blood glucose meter to do a check of our glucose level...

...continuous glucose monitoring is another med device, which includes a tiny glucose-aware sensor inserted under the skin & a quarter-size ride-along transmitter. Every few seconds that dynamic duo sends the info to a receiver, which shows the glucose level number. Thing is...

many CGMs work better when you check your blood glucose with a fingerstick and meter and share that number with the CGM a couple times a day so the CGM can check its numbers against a standard (the meter) to make sure it is working accurately. So strips needed for that.

prior to ... that means before. OK, get ready. Next up is a rather long list of times or events for which it is recommended to do a blood glucose check. Using a strip. Each time.

meals and snacks ... that means every meal. Every snack. I don't know about you, but I usually eat three meals a day. That's 3 strips.

at bedtime... that means "when you go to bed." So, usually one time in any 24-hour period. It's true--the guidelines do not specify "at naps." So, bedtime. That's 1 strip.

occasionally postprandially ... A mouthful. Pun intended. That means sometimes after meals. The count here depends on many things. In particular, before and after meal glucose checks are helpful in figuring out how to give the right amount of insulin for a similar, future meal...

...sometimes I may have body, or stress, or food changes that require me to do this quite a few times in a week. Let's just say 1 strip per day.

prior to exercise... that means before exercising. Note: exercising may include more than a session at the gym. Gardening, helping a friend move, playing tag with the kids= exercise. Sometimes I both exercise & garden during a day. But still, let's call it 1 strip.

when they suspect low blood glucose...that means when I think—because of symptoms I feel or because I have experienced a low before in a similar situation—my blood glucose may be low, or is heading down very fast. Low = 70 mg/dL or less, on a meter (strip needed) or CGM...

...the number of times per day a person using intensive insulin therapy may think they are low can vary greatly. Today I had 2 such times. Other days I may have more. Some days I may have none. I need to have strips at the ready, just in case. Let's lowball it, and say 1 strip.

Important: If low blood glucose is not treated (by eating or drinking something sugary)—the person having the low can pass out. Without help from others to treat the low, that unconscious person can die. Rare but it happens. Checking for lows & treating as needed = smart.

after treating low blood glucose until they are normoglycemic...that means about 15 minutes after eating or drinking something sugary, check to see whether blood glucose is above 70 (or the number your doctor told you is safe). If it's not yet above 70, treat and repeat. 1 strip!

and prior to critical tasks such as driving...critical tasks are activities during which having the physical or mental symptoms of a low could cause you or others harm. This does not mean don't DO those activities. It means use strips before you get going! 2 strips (round trip).

So now for a little bit of math. First, the minimal number of strips I am prescribed to use daily (If I don't drive, exercise, do an after-meal check, think I'm having a low, treat a low, or calibrate my CGM) = 4.

Second, the number of strips I am likely to use daily if I have a typical, busy, productive day (with no lows or CGM) = 7.

Third, the number of strips I am likely to use daily if I have a typical, busy productive day wearing my CGM and with 1 low, treated (no after-meal check) = 11.

Sometimes, I lose a strip. I'm careful with these tiny self-care necessities. But I have: accidentally dropped an unused strip into a sink of water, a mud puddle, and a sticky blob on a table at McDonald's. There's one I can see but not quite reach in the gap next to my car seat.

So, me and my doctor have decided that, given the standards of medical care in diabetes, my therapy, and my needs, I will use, on average, 8 strips each day. That is 240 strips in 30 days. My insurance plan has a limit of 200. I would like to see THEIR math. My doctor (not me)...

can ask for a quantity over-ride. That means more strips than the 200 limit. Done! I suspect (that means I think) the health plan will OK the over-ride and begrudgingly allow me 240 strips. Of course, strips come in vials of 50 and 100. Will the plan round up???

@AmDiabetesAssn guidelines say about blood glucose monitoring with intensive insulin therapy: "For many patients ... this will require testing up to 6–10 times daily, although individual needs may vary."

So, the daily number of strips, on average, that my health plan has decided it will cover (unless I object, ask my doctor to advocate on my behalf, and have a favorable response after a 72-hour review): 6.66
That particular string of numbers has many interpretations.

Dear Anthem UM Services, blood glucose test strips are not a medication. I did not try two other similar “drugs” on the formulary because I DO NOT OWN the meter models needed to “try” them. So I guess you could say I “did not respond well.”

The strips I use to help manage my intensive insulin therapy regimen are for a meter that I use to wirelessly send my blood glucose level to my insulin pump when I need to dose insulin. This means less chance of user error in entering a BG reading.

I shall continue reading the 5-page letter you sent, Anthem UM Services.

Looking forward to speaking with you!

Aha. If I don’t agree w/ the decision, I have 180 days to ask for a grievance, aka “appeal.” If I am currently getting care, and I or my doctor believe my condition could involve imminent and serious threat to my health, I can get an urgent grievance, with a decision in 72 hours