Challenging Medicare

[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.