BCBS insurance coverage for Artificial Pancreas type pumps

I was trying to search for information regarding requirements for getting a new insulin pump next year. I have a Medtronic Revel but am thinking about waiting for the Tandem Control IQ pump. I found this information and was wondering if anyone has had issues with their insurance covering the new updated pumps that act as an artificial pancreas.

“Replacement or upgrade of existing, properly functioning equipment, even if warranty has expired, does not meet Blue Cross and Blue Shield of Alabama’s medical criteria for coverage”.

So does this mean when my warranty expires they won’t provide coverage for one of the new pumps?

Hi @Kristy13, Anthem BCBS usually posts their UM guidelines on the web. It’s possible the the Alabama plan is more restrictive, but you should be able to have your Endo tailor the request to fit the guidelines. Unless you check all the boxes, be prepared to be denied. Appeal as necessary and you should be successful. The main Anthem BCBS UM guidelines are here.

When I upgraded 4 years ago with BCBS (Illinois), I was told something similar that just an out of warranty pump doesn’t qualify. I had a small crack in my screen and they used that for justification. With my current pump I have a small crack in the case so I plan on using that.

This seems to be the trend. I hope they will then provide quick turn around to cover new pump when the old one fails. When using out of warranty pumps, need to make sure you have backup plan and sufficient supplies to cover the potential gap.

My Endo new how to fill out the required paper work and the sales person for Medtronic helped with some extra wording.

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If you are someone who has had frequent lows during the night, or perhaps have had a time or times when you lost consciousness from a low or an ambulance had to respond, your doctor documenting this as part of your request makes a great deal of difference. And blue cross has a good denial review process staffed by medically trained people (my sister, a nurse, worked for them), not just clerical people.

Christine

there is no such thing as an “artificial pancreas pump”. NONE.

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Thanks for the information. I know with my previous pump before I did a Medtronic upgrade I had to go through the denial process. My Endo last year mentioned that she thought it wouldn’t be a good option. I just am hesitant to try the Medtronic 670G. I did find a Tslim pump brochure when leaving the doctor last time. So I might try calling their representative. Plus my warranty doesn’t end until next year.

I have Hypounawareness and have had a lot of issues with lows. The problem is currently I prefer to let myself run higher so that an avoid the lows. My doctor even has told me if I am at 220 (or below) not to correct anything at night. I definitely think I should qualify for the newer type pumps but I worry I won’t because of trying to avoid lows. So I don’t have lows as much. I constantly manipulate settings on my pump. I actually have started suspending myself because I am too tired to get up and treat an upcoming low.

Dave, the information I found showed this description below. I think they have more strict guidelines for these newer systems that work with CGM.

“Artificial pancreas device systems link a glucose monitor to an insulin infusion pump that automatically takes action (e.g., suspends or adjusts insulin) based on the glucose monitor reading. These devices are proposed to improve glycemic control in patients with insulin- dependent diabetes, in particular control of nocturnal hypoglycemia.”

Thanks, I usually try to run higher and my doctors in the past don’t want my A1C’s to run too low. I have had a lot of lows and have Hypounawareness. I’ve been lucky though because I haven’t needed assistance for lows. I have been able to treat on my own. I have had my blood sugar down to 20 and not passed out from it. When a I have been at an A1C less than 7 in the past my Endo mentioned I had too many lows and we adjusted to aim for above 7.

Although not speaking for @Dave44, it is possible that I share a similar mindset here.

“Artificial Pancreas” implies a significantly greater degree of functionality and capabilities then currently exist on the market.
I would not trust any sales person using such a term as either they are confused on what they are selling or they are simply lying.

I don’t like hype that does not match reality.

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Yes I agree with what you both are saying. That was just the wording on the BCBS document that was posted online. I think basically they are saying they have strict guidelines for allowing coverage for these updated systems like the Medtronic 670G.

I concur with the entirety of your post, Tim. :slight_smile:

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Understood. But words do matter. It is a shameful practice for companies, bloggers, and “journalists” to include in the title of any article relating to insulin pumps, the term “artificial pancreas”. There are actually people who believe that stuff. It’s about on par (but more dastardly) than the promise of moving sidewalks and flying cars that were promised back in the 1950’s.

I definitely understand where you are coming from. But, I just was quoting the wording that my insurance company used in their documents. They also had this listed below. So I guess the FDA uses this phrasing too? I’m not sure. Well unless the person who put the document together with my insurance company misquoted the FDA.

“According to the U.S. Food and Drug Administration (FDA), an artificial pancreas is a medical device that links a glucose monitor to an insulin infusion pump and the pump automatically reduces and increases subcutaneous insulin delivery according to measured subcutaneous glucose levels using a control algorithm. Because control algorithms can vary significantly, there are a variety of artificial pancreas device systems currently under development. These systems span a wide range of designs from a low-glucose suspend (LGS) device systems to the more complex bihormonal control-to-target systems. A 2016 horizon scan review identified 18 automated “closed-loop ” or semi-automated systems under development worldwide.
FDA has described 3 main categories of artificial pancreas device systems: threshold suspend device, control-to-range, and control-to-target systems. With threshold suspend device systems, also called LGS systems, the delivery of insulin is suspended for a set time when 2 glucose levels are below a specified low level indicating hypoglycemia. With control-to-range systems, the patient sets his or her own insulin dosing within a specified range, but the artificial pancreas device system takes over if glucose levels outside that range (higher or lower). Patients using this type of system still need to check blood glucose levels and administer insulin as needed. With control-to-target systems, the device aims to maintain glucose levels near a target level (e.g., 100 mg/dL). Control-to-target systems are automated and do not require user participation except to calibrate the continuous glucose monitoring system. Several device subtypes are being developed: those that deliver insulin-only, bihormonal systems, and hybrid systems.
To date, 3 artificial pancreas device systems have been approved by FDA. Two are threshold suspend devices. The other includes a threshold suspend feature and a semiautomatic adjustment of basal insulin levels. The third device uses a combination of control-to-range and control-to- target strategies.”

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LI have often seen a pump/CGM combination referred to as an artificial pancreas. It bothers me to some extent, but as a long term pump/CGM user, I know better. However, I can see where it would be misleading to a non pump user. A true artificial pancreas would also have the capability of infusing glucose when the sensor detected a low BG situation.

https://www.fda.gov/medicaldevices/productsandmedicalprocedures/homehealthandconsumer/consumerproducts/artificialpancreas/ucm259548.htm

Agreed with @Don1942, @Tim35 and @Dave44 about how a “true” artificial pancreas should function. FDA’s description of the “artificial pancreas” with only one insulin infusion system is scientifically incorrect. In order to be considered as artificial pancreas, the system must be able to infuse glucagon at low BGs after suspending the insulin infusion. Suspension of insulin infusion alone may not be able to “stop” hypoglycemia if too much bolus insulin is injected at meal time. The current hybrid or open-loop systems, such as, Medtronic 670G/Guardian CGM, or Tandem/Dexcom CGM Basal or Control IQ system (available in 2019) is only designed to infuse insulin to treat high BGs and suspend the insulin injection at low BGs to “prevent” hypoglycemia. However, it lacks of the capacity of glucagon infusion to raise the low BGs to the target range to “stop” hypoglycemia without human intervention. In other words, users need to eat sweet stuffs to raise BGs at low BGs if required. The current insulin infusion system with Control IQ software is not perfect solution, but it is an acceptable and cost-effective method at the present time.

My ENDO suggests wait until Bionic Pancreas system is available in the next years, as that system has both insulin and glucagon infusion devices and requires only body weight input without the carb counting for the correct amount of insulin injection. It would be closer to a “true” artificial pancreas.

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The iLet (Beta Bonics) is the pump I have been dreaming of for years. Insulin and glucagon from the same pump, connected to a Dexcom CGM. It will lower and raise the basal rate based on a Dexcom sensor. And the best part for me is no carb counting. You just tell it whether it is a small, medium or large meal and it will learn over time what that means for you. Such joy to never have to carb count! I have heard this pump is still in trials and it will launch with just insulin first. Glucagon has been the stumbling block but they are now ready for that part.
I also wanted to wait but will be going with the Tandem X2 for now. I’ll take the predictive low suspend as lows are a problem for all of us. But technology and the future looks promising!

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BCBS paid coverage for the 670G in IA when my old pump’s warranty expired. I had the documentation from my doctor. This pump system still does not work for me. It took more than 30 days to learn this and the company will not take it off my insurance to allow for a better fit through insurance for me. If you get it and have any problems at all return it before 30 days. The local rep cannot get his own company to send him the form to approve the return! Really watch the 30 day return policy that they don’t tell you about except in the fine print.

To Sally and Wayne, I too look forward to more automated pumps such as u each mentioned. However, I’ve got to wonder just how pricey glucagon will be as another med to load into a pump. Another thing; the newest pumps sure don’t seem to be very reliable, and the added complexity of a more autonomous pump sends shivers down my spine for the cost and the potential for failure. And I didn’t even get onto the subject of sensors, which currently are going to be 10-20 minutes behind, and not always accurate. Furthermore, current insulins last too long when injected SubQ, so that’s another bugaboo for a truly autonomous pump. No?