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CareLink and Bolus Wizard are registered trademarks and mySentry is a trademark of Medtronic MiniMed, Inc.

©2011 Medtronic MiniMed, Inc. All rights reserved. 9404507-011 20111111

MYSENTRY R

E I M B U R S E M E N T

TOOL KIT

To purchase the mySentry Remote Glucose Monitor from Medtronic, you will need a prescription on file at Medtronic from your healthcare provider and a method of payment. Medtronic has assembled this tool kit composed of sample documents and information intended to help assist you in pursuing coverage (if you choose to) from your insurance company either before you purchase mySentry, or, after you purchase it. Please be aware that coverage of new medical technologies by insurance companies is a long process and may include several appeals.

Every insurance company has different rules and processes, so the information provided here should be used as a general guide. Be sure to check with your insurance company for their specific

documentation needs and processes including who the coverage request must come from as well as the details on how to submit your request.

DOCUMENTS FROM

YOUR HEALTHCARE PROVIDER

1. Prescription from Your Healthcare Provider

Your insurance company will want a copy of your prescription.

2. Letter of Medical Necessity

Ask your healthcare provider for a letter of medical necessity The purpose of the letter is to confirm why you (the patient) are a candidate for mySentry and should include: ƒ A clear explanation of the medical necessity from your prescribing healthcare provider including:

¾ Your demographics

¾ Your diabetes history

¾ Any current diabetes-

based challenges you are experiencing which mySentry would solve CareLink and Bolus Wizard are registered trademarks and mySentry is a trademark of Medtronic

MiniMed, Inc.

©2011 Medtronic MiniMed, Inc. All rights reserved. 9404507-011 20111111

3. iPro Tracing (if available)

If your healthcare provider has recently put you on an iPro for 3-days, then including a copy of the tracings may provide additional data to support the medical necessity.

4. Durable Medical Equipment Coverage Request Form (sample form included)

Complete all sections of the mySentry coverage request form: ƒ Have your healthcare provider fill in the NPI number information as well as the patient diagnosis codes needed on the form. ƒ Work with your healthcare provider to provide any clinical information to support the medical necessity of using the mySentry Remote Glucose

Monitor.

ƒ Attach all supporting documents requested by your insurance company to this form as well as complete the attachment check boxes on the bottom of the form.

DOCUMENTS PROVIDED BY PATIENT

5. Copy of Invoice

This is needed only if you have already purchased mySentry and are asking your insurance company for reimbursement. To obtain a copy, email rs.pfsinvoicerequest@medtronic.com and include:

Your request for a copy of the invoice

You will receive a copy of your invoice via email within 24 hours.

6. Letter From Patient Requesting Coverage (sample letter included)

Submit a letter from yourself requesting coverage approval. The letter should explain: ƒ Your purpose (to request coverage for mySentry). ƒ Review your specific insurance plan and use the language it contains to ƒ Personal medical history to demonstrate medical necessity. For example, detail how often you experience hypoglycemia, ambulance or hospital visits. Provide specific incidences requiring medical intervention which mySentry monitoring could likely mitigate ƒ Request approval for mySentry and ask for the next steps in the process.

CareLink and Bolus Wizard are registered trademarks and mySentry is a trademark of Medtronic MiniMed, Inc.

©2011 Medtronic MiniMed, Inc. All rights reserved. 9404507-011 20111110

7. Description of mySentry

Your insurance company will want details about mySentry and how it works. To obtain descriptions and photos of the system, log onto www.medtronicdiabetes.com/mysentry and print the sections that provide the information your insurance company requires.

8. Recent Blood Sugar Logs (if available)

Similar to the iPro tracings, if recent blood sugar logs are available, then including a copy may provide more data to support medical necessity. The easiest way to gather your blood sugar readings is with CareLink® Personal. Since your insulin pump requires fingerstick readings for your Bolus Wizard® feature and to calibrate your CGM, there are blood sugar readings stored in your pump. Simply upload your insulin pump into CareLink Personal at www.medtronicdiabetes.com/carelink. Then within CareLink Personal, select the "Reports" tab and choose the "Logbook Diary" report after you have uploaded your device data.

APPEAL PROCESS

Pursuing coverage for new technology often requires an appeal (or two). After your initial request for coverage, your insurance company will send you a letter agreeing to your request or denying it. If you receive a denial, review the letter for details on how to submit an appeal. Gather whatever information your insurance company has asked for and re-submit.

1. Appeal Letter From Patient (sample letter included)

Submit a letter from yourself requesting an appeal. The letter should include: ƒ Your purpose (to appeal your coverage request for mySentry). ƒ Specific mention of the reason your insurance company denied your initial request and documented reasons why the company should re-evaluate. ƒ Any supplemental information your insurance company has requested. ƒ Repeat your request for approval for mySentry. IMPORTANT After all your best efforts, please be aware the mySentry

Remote Glucose Monitor -

with your insurance plan may not be reimbursed to you in full. So be aware that any balances not reimbursed by your insurance plan up to the full purchase price would be your responsibility.

SAMPLE PTLPINPRT

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SAMPLE PATIENT R

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SAMPLE PATIENT APPEAL LETTER

Date Name

Insurance Company name

Address

City, State and ZIP Code

Re: Patient"s Name

mySentry™ Remote Glucose Monitor Group number: [ ] Policy number: [ ]

Dear [insurance company contact],

Please accept this letter as an appeal from [patient"s name] regarding the decision by [insurance company name] to deny coverage for the mySentry™ Remote Glucose Monitor, which provides a simple and reliable way to remotely monitor the Paradigm® REAL-Time Revel™ insulin pump that is worn by [patient"s name]. This device is ideally suited for night time use, when caregivers worry most about glucose variations. It is my understanding based on your letter of denial dated [mm/dd/yy] that this procedure has been denied because: [Quote the specific reason for the denial stated in denial letter.] As you know, [patient"s name] was diagnosed with diabetes on [mm/dd/yy]. Currently Dr. [ ] believes that [patient"s name] and their caregivers will significantly benefit from the use of the mySentry Remote Glucose Monitor. [Patient"s name] believes that you did not have all the necessary information at the time of your initial review. Attached is a letter of medical necessity from Dr. [ ]. Dr. [ ] is a specialist in the treatment of diabetes and the letter of medical necessity discusses the benefits of the mySentry Remote Glucose Monitor in more detail. Also included is the prescription from Dr. [ ], product information explaining the mySentry Remote Glucose Monitor, and information on how this device can be billed to [insurance company name] by the provider of service. Based on this information, [patient"s name] is asking that you reconsider your previous decision and allow coverage for this device as medically necessary as Dr. [ ] outlines in the letter. Should you require additional information, please do not hesitate to contact me at [xxx-xxx-xxxx]. I will look forward to hearing from you in the near future.

Sincerely,

Patient"s name or Parent / legal guardian for minorsquotesdbs_dbs14.pdfusesText_20

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