Challenging Medicare

[ali8]

Hello
Has anyone challenged Medicare, ie asked for an exception, to having to see your endo or prescribing Dr, every 90 days for your pump supplies to be continued based on your endo stating you are well controlled and years of use without problems? When I asked my endo and her clinics insurance team they had no idea how to do. Thank you for any help.

[CJ114]

Yes, but I am not quite sure what kind of an exception you are seeking to acquire. During Covid, doctors were not required to see you physically. Telehealth visits were acceptable, and I am not sure if those are still allowed or not. So, although seeing your endo physically was not a requirement, a visit had to have been executed through the doctor’s portal or zoom, if not in person. Until your endo makes your visit notes available for Medicare, you will not be able to get pump supplies past 90 days and Insulin and CGM past 180 days for patients on MDI. If your time between visits is, let’s say, 91 days, you will be able to get your supplies once the notes for that 91 days are received from your endo. No exceptions, and they don’t care if you are traveling out of the country, disabled, or any other reason you may think may be valid. The answer is No.

[Brianna1]

I’ve read about this 90 day requirement many times on this forum. This seems completely unreasonable to me! I am 20-25 years out from Medicare and so have nothing useful to add…it just makes me angry and dreading using Medicare when the time comes. As if we don’t have enough to worry about and hoops to jump through already…

[CJ114]

@Brianna1

This seems completely unreasonable to me! I am 20-25 years out from Medicare and so have nothing useful to add

Ah, but you have 20-25 years ahead of you to work hard at getting that rule changed if it truly annoys you. In that amount of time, you just may be successful. Those of us on Medicare now are, in the meantime, stuck to abide by their rigid rules.

[MM1]

@Brianna1

This seems completely unreasonable to me!

Unfortunately there are many that try to fraud medicare.

Maybe this is appropriate explanation.

Trust but verify

[spdif]

Medicare Decision Memos are a good starting point. The one on covering insulin pumps is well written. NCA - Insulin Infusion Pump (CAG-00041N) - Decision Memo

There are past discussions on this and I don’t think much has changed. Check out

Three-Month Medicare MD Visit Requirement?

Terry and others, here is where my question lies. Because I use the OmniPod, my PDM controller, my pump supplies (the Pods themselves), and my insulin are all covered under Part D. Medicare considers the OmniPod a drug rather than DME, and the insulin, then, goes under Part D also. The only thing that falls under Part B for me right now is the test strips (which Medicare considers DME); therefore, the only reason I would have to go to my Endocrinologist every 90 days is to get the test strips…

and

3 month visits to Doctor for Pump Users

Follow this link and click on 280.14 for Infusion Pumps. You will see the requirement under Medicare to see the treating physician every 3 months.

In those two threads others have asked about the 90 day requirement but no one mentioned where it came from. I did a little digging and found the LCD for pumps repeats the requirement and comments to change the requirement were determined to be out of scope of the LCD. So maybe don’t base your request on an exception to L33794.

Hopefully someone will have better info for you. I hope you are successful.

[PedsRN1]

You could try the Medicare ombudsman. They handle grievances, appeals and the like but you could start with contacting your specific plan first. As someone else mentioned I wouldn’t base your request on an exception if you are going to challenge. Usually that is for a need that is not covered or available access to those services.

[ali8]

Thank you everyone for your replies. I will alert my endo and anyone else I work with to approach this as a waiver request. I knew exception was not the best word, and in working with folks following regulations the language can really make a difference.

[CJ114]

What you may also look at is if you do succeed in getting a waiver, how will it affect your re-ordering process? Most re-ordering is now an automated process, and I have never seen a waiver option during reorder. Maybe if you get a waiver, you can have it put on file with your mail-order supplier so that you can reorder supplies. Otherwise, you may be stuck with only being able to get your supplies through a brick-and-mortar pharmacy. In diabetes, one generally never wants to limit their ordering and/or other options. - Good Luck!!! Let us know how it turns out.

[ali8]

Thank you, that has occurred to me also. I have had to adjust schedules with pump supplies in the past and it can be a real battle with the automated ordering process.

[mohe0001]

I feel for ya’, ali. This is gonna be a nightmare. Be sure to send word on how it all goes down. That way, if you don’t pull it off, maybe the next person who tries this can get a little farther.

[pstud123]

I “saw” my endo 3 times last year. Last time I saw them they said that if I continued to do as well as I have been, we’d increase the interval between visits to 6 months. I guess I need to question how we can do that.

My endo wrote orders for a pump, CGM and all supplies provided under Part B that were sent to a an approved Medicare supplier late in February 2022. They haven’t needed to write another for a year.

They did need certify to “seeing” me after 6 months and my insulin prescriptions have been for 2-90 day supplies.