I am so frustrated right now. I have put in a lot of work to trying to get an insulin pump. I read several forums and talked with other diabetics who have been able to switch to pumping. Over all I found that I would be able to stop doing as many shots, minimize my highs, and overall keep better control over my sugar levels. I got everything through the Animas Corp and they told me that Aetna required special lab work. After spending the money on the special labs and getting everything through I found out because I was type 2 (My Cpeptide levels were too high to allow me access to a pump). I was diagnosed in 2008, but it feels like forever now my stomach is jacked up and sore, I seem to manage to run into the scenario of not having my meds with me when needed because of something unplanned. At any rate I guess I needed to scream a bit about it, but if anyone has some words of encouragement or other options to try I would appreciate.
First, make sure you follow your insurance company’s appeal process. Also, work with Animas to get through that process. They have a vested interest in getting you approved and they also have the knowledge/experience in doing so. Do you have a certificate of medical necessity? Technically, the insurance companies are not supposed to deny you once a doctor writes a certificate of medical necessity. They can initially deny you, but if the doctor says it’s necessary, I believe they are supposed to approve it.
Years ago, even type 1s had to jump through all these hoops to get a pump. They would tell us that our A1C was too “good” to have a pump, and then they would tell us that our A1C was too “bad” to have a pump. The criteria were always mysterious. It took some time, but eventually pump therapy became a generally-accepted standard of care for T1D, even as far as insurance companies were concerned. I think that the same thing will eventually happen for T2D folks. I personally think the reliance on labwork is absurd, because labwork just captures one moment in time, and not usually what is happening on a day-to-day basis.
Don’t take no for an answer. Appeal the denial. When I went through this (with Aetna, also), my claim was denied even though my son is Type 1 and his doctor wrote a letter advocating for the pump for him. I had to send in documentation of the difficulty we’d had maintaining good control for the 10 months prior to my switch over (not hard to do, his a1c was 8.4!) and show that he’d been to see his endo at least 3 times over the past year (also not difficult). The person who reviewed the appeal was not an insurance adjuster – it was an actual MD on Aetna’s staff. Generally, if your request is medically reasonable, the reviewers will overturn the original denial. If you don’t have this documentation, then you should make a point of starting to keeping records of your diabetes management regimen so you can make a case for why pumping is necessary. Track your BGs throughout the day the way T1s do – recording all your BG readings, your carb intake, and your insulin usage as well as any other meds you take (how much and when you take them is important). Take your BG frequently during the day so you can SHOW them that you’ve made a real effort to keep your BG under control but have not been successful. Try to take them in the middle of the night, too, so you can demonstrate BG instability overnight – that is a classic reason for putting someone on the pump too. HOpe this helps!
I have Aetna and consider the pump criteria highly biased against T2s. Aetna follows the medicare guidelines to the letter as a way of avoiding having to pay for insulin pumps. In order to qualify, you either have to have T1 or a fasting c-peptide of 110% of the lower reference range. For a T2 with significant insulin resistance, the c-peptide threshold represents almost total pancreas failure.
So you’ve failed to get through the first hoops. But that doesn’t mean you can’t appeal. As others have noted, there is a process. And the key to winning at this game is to employ good players with a proven track record on your team. You need a doctor with proven success at getting T2 approval from Aetna on pumps to write you a letter of medical necessity. And that may not be your current doctor. The Animas rep can probably point you to a successful doctor. And remember, you need to demonstrate “medical necessity.” Just hating shots doesn’t count.
So I feel for you. I am in the same boat. I’ve even had Aetna tell me themselves about how great a pump is, but I also know they will fight to not have to pay for it. Eventually, we should see more studies showing that T2s achieve better outcomes on a pmp and the pump will become more accepted for T2s. But it will take time.
Thank you everyone your words of encouragement, and advice have really put me in a better mood about this whole thing and shed some light on different paths to try and take. I appreciate it.
Looks like MyBustedPancres, Elizabeth, and bcs has given you some good advice here. Just don’t take no for an answer. I got one for you…I’ve been pumping for 23 years now and been a diabetic since I was 10 and my insurance made me take all the test to see if I was producing any insulin. HUH??? Anyway after 13 vials of blood it came back that I was telling the insurance the truth and not trying to rip them off. I felt like telling the guy at the insurance company that if he read my medical records he would see that nothing had changed for 38 years! SHEZ!!! I did tell him what I thought of his policies and he actually agreed with me. LOL!
Thanks again everyone. So I talked to the Animas Sales Reps, and a supervisor for them called me. Apparently all this was based off Aetna’s guidlines, and not actually denied yet. So after reading your responses I said well put it through for denial so I have some grounds to start fighting that decision on. The Rep put it in for medical review denial, and got back to me today… I was approved! I am so excited, I keep wanting to say pumped, but it sounds to punny lol… Anyway thanks again for all your advice and help I don’t know if I would have kept pushing without your help.
That’s great news! Glad you posted an update too, as it will hopefully help others understand that sometimes you have to push a little to get what you need. The pump is a great D management tool. I have T1D, but I’ve seen many T2D folks on here report benefits of using the pump. Keep us posted.