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In the first three months after getting his Dexcom continuous glucose monitor, Ric Peralta听said, he reduced his average blood sugar level听by 3 percentage points.

鈥淚t took me from not-very-well-managed blood sugar to something that was incredibly well managed,鈥� said Peralta, a 46-year-old optician in Whittier, Calif., who was diagnosed with Type 1 diabetes in 2008.

Peralta was so enthused that he became a 鈥淒excom Warrior,鈥� a sort of grassroots spokesman for the product. It became hard to imagine life without his new monitor, a device that lets him track the trends in听his blood sugar 24 hours a day on his smartphone. And yet, he has spent weeks at a time without the device over the past year because of insurance restrictions. Physician groups and patients consider those rules burdensome, but insurers defend them as necessary.

Diabetes听听and听听have started to focus attention on the听, leading to听,听听and听. But insulin isn鈥檛 the only thing people with Type 1 diabetes are struggling to get. Managing the condition requires other essential, often lifesaving medical supplies. And patients frequently face hurdles in getting access to those supplies 鈥� hurdles put in place by insurance companies.

A Life-Changing Device

Peralta learned about the latest version of the Dexcom continuous glucose monitor from the mother of one of his patients. He visited the company鈥檚 website and, within two weeks, the device was shipped to his front door.

鈥淚 still didn鈥檛 100% appreciate exactly how it was going to change my life,鈥� Peralta said. 鈥淚t was amazing.鈥�

Typically, people with Type 1 diabetes check their blood sugar by drawing a drop of blood from a finger and placing it on a disposable test strip that鈥檚 read by a blood glucose meter. Doctors suggest checking blood sugar this way between four and 10 times a day. These readings are crucial for helping people with diabetes manage their blood sugar 鈥� keeping it from getting too low, which can lead to sudden seizures and loss of consciousness, as well as from getting too high, which can cause vision loss and nerve damage and can even, over time, lead to amputations.

Instead, Peralta鈥檚 continuous glucose monitor gave accurate blood sugar readings every five minutes. That鈥檚 288 readings a day, or about 278 more readings than even the most conscientious patients get the old-fashioned way.

鈥淲hen I had to do the old-fashioned finger prick test, I was only doing that right before I ate, so I could see how much [insulin] I was supposed to take,鈥� Peralta said. (People with Type 1 diabetes have to take multiple daily shots of insulin to keep their blood sugar within the normal range because their bodies stop producing the naturally occurring hormone.)

In their home in Whittier, Calif., Lisa Peralta pats Ric鈥檚 Dexcom sensor to make sure it鈥檚 staying on his arm. Before he got the device, Ric had to check his blood glucose via multiple finger pricks and plastic test strips every few hours. (Allison Zaucha for NPR)(Allison Zaucha/NPR)

鈥淚 didn鈥檛 realize that I had rather severe [blood sugar] peaks and valleys in between my mealtimes,鈥� Peralta said.

Tighter control of blood sugar can听听of heart disease, kidney failure and nerve damage. For Peralta, it also offered peace of mind.

The monitor sounds an alarm when his blood sugar gets dangerously low; Peralta said his co-workers have started bringing him sugary snacks when they hear the alarm, to help him raise his blood sugar back to normal. When he takes his family on road trips 鈥� a favorite activity 鈥� he no longer has to worry about the possibility of passing out while driving.

鈥淚t even syncs with my car so I can just say, 鈥楽iri, what鈥檚 my blood sugar?鈥� And it will come over the car stereo system,鈥� Peralta said. 鈥淚鈥檓 safe for my family.鈥�

Prior-Authorization Requirements

When common chronic conditions such as diabetes are well controlled, it prevents worsening disease and saves money for the health system and the patient.

But Peralta said his efforts to use this new tool consistently to manage his diabetes have been stymied by insurance problems that began about a year ago.

The newest Dexcom continuous glucose monitor has three parts: a sensor that measures glucose levels, a transmitter that sends out the sensor鈥檚 readings wirelessly and a receiver that displays those readings on a screen.

For each of these parts, Peralta needs 鈥減rior authorization鈥� 鈥� a requirement that his physician get approval from his insurance company before prescribing the device.

The Dexcom sensors last about 10 days each, and Peralta鈥檚 insurance allows him to buy a three-month supply at a time. But he also has to get prior authorization for each supply, meaning every three months his doctor needs to reconfirm with his insurance company that the sensors are medically necessary. Same goes for the device鈥檚 transmitters 鈥� which听last about six months each.

鈥淚 have to jump through hoops and they have to jump through hoops to get information from my insurance to get authorization,鈥� Peralta said in frustration, adding that 鈥渇or the last year, basically every time there鈥檚 been something that鈥檚 gone wrong.鈥�

鈥淧rior authorizations are in place to protect patients, to improve safety and to try to make sure that the care they receive is as safe as possible and also as affordable as possible,鈥� said Kate Berry of the trade group America鈥檚 Health Insurance Programs.

But to Ric Peralta, the requirement is a burden.

The most recent snafu happened in March. Peralta ordered a new supply of sensors directly from Dexcom but said the company submitted a request for approval of a new transmitter as well. And because his insurance approves the sensors and transmitters on different authorization timelines, the whole claim was denied. Peralta estimates he spent four hours on the phone with Dexcom and his insurer over the next month and a half to sort it all out. During that time he had to revert to finger-stick tests.

鈥淚t鈥檚 maddening,鈥� Peralta said. 鈥淚f I do not have my proper management of this disease, I鈥檓 going to die from it. And they鈥檙e making it as difficult as possible.鈥�

A Burden On Doctors, Too

Prior authorizations have become a major concern of physicians across the U.S. health care system, as evidenced by a December .

Of the 1,000 physicians surveyed, 91% said prior authorizations 鈥渉ave a negative impact on patient clinical outcomes鈥�; 75% said the requirements 鈥渃an at least sometimes lead to patients abandoning a recommended course of treatment鈥�; and 28% said the prior-authorization process had 鈥渓ed to serious or life-threatening events鈥� for their patients.

鈥淚n my practice, we have five individual physicians, and we hired five full-time employees whose primary duty is obtaining prior authorization and dealing with insurance companies,鈥� said Dr. Bruce Scott, an otolaryngologist from Kentucky and speaker of the AMA House of Delegates.

鈥淧rior authorization is a burden on providers and diverts valuable resources,鈥� Scott said. 鈥淭hat鈥檚 a problem.鈥�

The AMA has even听 that catalogs stories of patients and providers who say they鈥檝e struggled to gain access to important medical products and procedures because of problems with getting prior authorization from insurers 鈥� everything from pain medication for a cancer patient to X-rays in the ER. Scott said the AMA doesn鈥檛 expect insurers to completely do away with requirements for prior authorization, 鈥渂ut we believe that it should be focused and that it should be better planned.鈥�

The American Association of Clinical Endocrinologists 鈥� an organization of the physicians whose specialty is often associated with diabetes treatment 鈥� goes further.

鈥淲e feel that physicians that are specialists in endocrine disease should not be required to fill out prior authorizations for endocrine treatments,鈥� said Dr. Scott Isaacs, an endocrinologist from Atlanta and a member of the board of directors of AACE.

鈥淚t鈥檚 a huge burden for the patients trying to get this sorted out. Sometimes it鈥檚 red tape; sometimes it鈥檚 a true denial,鈥� Isaacs said. 鈥淚t鈥檚 a huge burden for the doctors as well, and the doctors resent it.鈥�

Berry, of America鈥檚 Health Insurance Programs, acknowledges there鈥檚 room for improvement in the prior-authorization process. In fact, in January 2018, the AMA and AHIP signed a identifying five areas for improvement. It was co-signed by the American Hospital Association, the American Pharmacists Association, the Blue Cross Blue Shield Association and the Medical Group Management Association.

Who Bears The Greatest Burden?

For Ric Peralta, the ultimate burden of getting all these prescriptions filled falls on him and other patients like him.

After his latest mix-up with the sensors in March, he discovered the battery in his transmitter had died.

Peralta made another frustrated call to Dexcom, and recently got a complimentary transmitter to get him back on the system while his formal order goes through the approval process.

鈥淚鈥檓 quite nervous about what鈥檚 going to happen again in two months when I am needing to call in orders again,鈥� Peralta said.

鈥淎m I going to have to go through this whole thing over again?鈥�

This story is part of NPR鈥檚 reporting partnership with Kaiser Health News.听