I didnt want to make (yet another) thread about insurance companies and their sometimes unrealistic requirements to get the things we need to manage our D. Theres plenty of those. But rather, Id like to hear what others have done to get around these requirements? Ill start.
My Animas pump is end of life this year, and its time for a new pump. Im really only interested in the Minimed 670G (closed loop system). In the meantime, until they are released in June, they have the 630G. With my insurance the upgrade from the 630G to the 670G is free so I want to hop on now. My new insurance as of Novemember this year has proven so far to be the best insurance Ive had, and they have a long list of requirements to qualify for a pump and CGM; however, one requirement for CGM is I need an A1C of 8 or greater, which I havent had in I dont know how many years. Theres no way around it (my endo has tried).
Sooo…my solution is Im going to run at a goal of 200 for blood sugars and retest A1C every 3-4 weeks until I get an 8. It will probably take 30-45 days. Yes, Ill feel like crap, but in the long run it will be worth it (to me). My endo isnt too excited about this, but as I told her, its my decision.
A bunch of you know me already, but for those that dont Ive had a good run with my D. Last November was my 50th anniversary of living with T1D (I was dx’d at 10 mos), and the only complications Ive had is some retinopathy. Ive been very lucky. But Im willing to run high for a few weeks to get the closed loop system, which, IMHO, is one of the greatest breakthroughs in T1D treatment in my lifetime, next to home glucose testing and insulin pumps in general, which didnt exist when I was growing up.
So what are some things you all have done to get around insurance requirements to what you needed?
Often a requirement such as of A1C > 8, applies when you don’t already have a pump. You will likely need letter of medical necessity from your Dr, asserting that staying on a pump allows you to maintain your A1C and prevent complications.
Then other than your idea to get an 8, the appeals process might be the only other way.
I recall seeing a post one time where someone intentionally over dosed insulin, to get into emergency room with severe hypo, to meet his insurance rules.
I have no objection to playing the insurance game to your long-term benefit but I fear possible unintended consequences. An A1c of 8.0% means an average blood glucose of about 183 mg/dL. If you caught a cold or other virus, you open yourself up to all kinds of risk.
For example, if you ended up in the hospital, for any reason, high BG levels make you susceptible to infection with a super-virus with no known antidote. That will likely not happen, but could.
It’s your decision, of course, and I understand your motivation. I see insurance policies like this as evil.
Nope once they pay for it, thats enough. I wont have to continue with A1C that high.
And our goals are very individual. Personally, 120 is perfect If kept at 120 that would be an A1C of just under 6. Dunno why youd want lower (as a T1). But we’re all different
When I completed information for my pump and Dexcom cgm they wanted to know things like complications, lows, other things. I know I have hypo unawareness so that definitely helped me qualify. I received a denial which might be standard for most. So I sent in an appeal with a letter stating that these items would help with my frequent lows, nighttime lows, and hypounawareness. Also, that by having these items it could prevent my having to go to the ER, hospital or doctor more often.
Dan, I would just sue them. I generally run an A1c of about 5.5-5.9. Standard deviation of 20-25. Today was a really bad day, I’ve been averaging 180 all day and I’ve felt like crap and have been quite testy. I could not imagine doing this long enough to get an A1c over 8.
BEFORE YOU DO THAT…
Have you exhausted your appeals yet? You are guaranteed, by the ACA, an external review with an independent review organization (IRO). There is a thing called the federal standard of care that you can reference in the appeal.
I believe that this policy does not comply with the federal standard of care, and I think you would have a chance of winning your appeal.
I am not sure about this, but another way to qualify for a CGM is wide ranging bs, not just overall A1c. Hypo unawareness is always a plus to the insurers even though it is not a plus to any of us T1’s. I think a CGM should be accepted before a pump as for necessary equipment for a person with T1. I know quite a few T1’s who do very well with MDI and CGM.
Oh, I’m so sorry. That’s infuriating. There are a few tactics I would try:
If your doctor has not written a letter of medical necessity, but only submitted appeals, have your doctor write a letter of medical necessity. My understanding is that this is a legal document. He or she can include research papers, any historical proof showing how being on a pump helped you get your A1c to a good place and keep it there, and of course, the fact that you as the patient are going to have to voluntarily put your health at risk of serious complications in the short and long-term if they do not provide you with the pump immediately. You can help your doctor work up this letter. Sometimes it’s helpful if you do some of the legwork for them in terms of digging up your past medical records and conducting PubMed searches.
Call and threaten to file a complaint with your state insurance commissioner. Tell them what you are telling us here. Call and file that complaint. File that complaint in writing as well. Cc the insurance company with contact information you gather from calling them.
Tweet to their social team. Tweet to the #DOC, tweet at your Senators and Reps. Get a hashtag going for your case. Let them know you are serious.
Contact large media outlets. Contact journalists who write for them. See if any of them would be willing to contact Media Affairs to investigate your case. Make it clear that this is an urgent matter. A Google search or Twitter search should get you some names of journalists or writers who may be interested in going to bat for you, if only for a story.
This is wrong, wrong, wrong. Keep us all posted. I’d love to make a visualization of your interactions with the insurance companies, as I’m doing in my own case, if you have good documentation of all of these extra interactions they are subjecting you too.
Yup. 45 years, no, none, nada complications, A1c 5.5-5.9. Never ever used a pump, never ever will.
And they’ll take that CGM from me out of my cold, dead hand.
Well, apparently all this was for naught. My ins. company has a separate set of qualifications for what they classify as “artificial pancreas devices”, of which the minimed 530G, 630G, and 670G fall under. Soooo…under those qualifications, Im covered. My new 630G will ship out today, and Ill upgrade to the 670G closed loop when its released.
Personally I dont think running at 180-200 for a few weeks will cause any harm.