Denied again, any help would be greatly appreciated

I am so mad right now I can not sleep. I was denied for my insulin pump again. I meet the requirements needed to be placed on an insulin pump with one exception. The one that I do not meet is pregnancy. I will not get pregnant just to be placed on a pump. (Sorry folk I am only going to go so far). I myself have come up with 28 reasons to be placed on a pump.

Do the insurance companies not realize that it will be cheaper in the long run to place me on a pump now and not wait until after the damage has already been done? Heck it is not like my insurance company does anything in a timely manner. I has taken me months to see an Endo. I saw the Endo in October and they submitted the claim to the insurance company. I have been making phone calls to the insurance company to make sure that my paperwork does not get misplaced. I want my pump. I thought if something was not experimental and a doctor prescribed it the insurance company was supposed to pay for it. I guess not. I guess my next option is a lawyer. I guess in my case the squeaky wheel gets denied.

Any words of wisdom from those who had trouble getting a pump approved would be greatly appreciated.

I, for one agree with you.In Windsor the Government will only cover insulin pumps for children under 18.What do these kids do when they turn 19 for their supplies?Will they have to pay out of pocket? It is very biased.If only they knew of the money that could be saved in treating complications.They say there will be 3 million with diabetes by 2010.I will be getting the pump soon and will have to pay for it.My supplies thankfully will be covered under my husband’s insurance.When I voiced my concern about seeing my endo for the pump they gave me an appointment 11 months down the road.I luckily got in sooner when I called about having trouble controlling my morning glucose.I can only hope that your insurance company will cooperate better.Good Luck.

I had a similar struggle that ended in succes! Actually the point that supposedly convinced my insurance company was my doctor writing a letter about nighttime lows (which involves an ambulance and a hospital bill & could happen in the near future, unlike complications). I think that the insurance companies don’t care about the REALLY long term (I guess they assume that they won’t be insuring you then…). But nighttime lows scared them. And it was actually a problem for me.

Just a thought… have your doctor write a letter to the insurance company emphasizing immediate cost savings, like preventing extreme lows. All the best!!

Good advice provided that the doc does not charge $25.00 for writing the letter which is the norm around here, and folks that is for multiple copies of the SAME letter, like for the flex plan funds and insurance picking up part for example would cost $50.00. Talk to some others who have the pump and see what they had to go thru…maybe pick up some pointers…also keep on trying…the more you file, and they have to handle the paperwork, often they cave and approve. It also makes a big difference if this is a self funded group or a large real insurance company. If it is self funded, and they go over budget paying claims, then they have to pay a penalty. Self funded groups are not known for being kind hearted and paying. (I have to have some dental work that will cost 4 grand…my plan pays 1 grand per year period, end of statement. So I am hoping to win the lottery or the Reader’s Digest sweepstakes)

I have called my insurance company and told them that I have jumped through their hops and want to know exactly what are the requirements for them to approve me for the pump. I was told they would send a letter to my doctor and I had to wait till the doctor got the letter. I am now waiting for a supervisor to call me back.

I applied to Medicare for a pump on June2, 2008. I have met all their requirements and an still waiting to hear from them. I do not like the idea of a bunch of guys sitting around a table, deciding whether Ishould live or die. I know this is an exaggeration, but that is the way I feel. I am really looking forward to better BG control, but am pretty disgusted with Medicare. Can anyone tell me how much longer I will have to waiit? It has been 5 weeks.

Call again and ask for a supervisor. Be sure that the company received your appeal. Have your MD do some work for you. Perhaps someone “went on vacation” and your letter is sitting on their desk or has not been prioritized.
This is your life. Call Medtronics Minimed and see if a representative there can meet with you and help you with this problem. They are very informative and may be able to direct you on how to proceed. Request that your MD write a letter of need , research it, and if your MD has already done this have them call to see if the letter was received if your can’t . Good luck. Lee

Damn, this sounds like me exactly, except, instead of pregnancy, my C-peptide result was THREE, count 'em, 3, points too high. Medicare requirements need to be overhauled and restructured, bigtime. I am going to try a different approach and see what happens. Medicare has already paid $250,000 worth of work done on my eyes due to diabetic retinopathy. Seems like a bunch of doctors would have the foresight to prevent this happening again Also. if my kidneys fail, the going rate for a transplant is in the neighborhood of one million dollars, but who am I to criticize Medicare’s methods?

they didn’t want to give me a pump, and my deductible was too high (5,000) - I paid for mine out of my pocket. Six trips to the ER wasn’t enough for the insurance company.

God Lord, Unicornzzz! I can’t believe that they WANT you to get pregnant! I guess each insurance company has different standards. I am on Medicare and one of the ones we fought about is that my pancreas is producing VERY VERY MINIMAL insulin. It actually met the numbers but someone was being an ah*e at Medicare. They finally drove it through! But not for CGM. Oh well.

One thing that you may want to investigate is your state’s insurance commissioner. Either threaten to bring them in or bring them officially into the fray. I am encouraged that they will fold because I used to work at the National Assn. of Insurance Commissioners (many, many eons ago) and found that insurance companies shiver at the thought of having to answer to the commissioner and may just buckle in to avoid a pain!!!

Good luck.

Lois La Rose, Milwaukee, WI

Unicornzzz: I just had a thought!! Yep, the old brain is really cookin’ now! Someone mentioned calling Medtronic and I agree. That is exactly what happened in my case. I was rejected because, I think, my c-peptide was REAL CLOSE to their requirements. I never knew this was happening til it was almost over. Between Medtronic and my DR, who is a favorite of Medtronic, they worked it out behind my back. The only thing was a delay in the supplies and then THAT was taken care of. Gosh, for once I guess I was LUCKY!

Lois La Rose

Medtronic has great payment plans, and they even have financial assistance I’ve been told for those who can’t afford it.

Hey Timothy,

I’ll be switching from shooting to pumping on the 29th of January. The minute I was eligible for Medicare, I went to my doctor and told him I wanted a pump. I didn’t have insurance before that and I had learned that the only insulin covered by Medicare is that insulin delivered by pump. Go figure. Well, my doctor wouldn’t prescribe a pump. Instead, he sent me to an endocrinologist. The endo agreed I should be on a pump and they started training me. He only prescribes MiniMeds. MiniMed had me take some tests, one being a C-Peptide. I had been insulin dependent for 49 years by then but was still creating just enough insulin for Medicare to refuse me.

I’m coming to the end… this past November, I finally passed the c-peptide barrier. I had the pump in my hands on December 23. Try working with Medtronics and their Medicare representatives, CCS Medical.

Hi, I was sorry to read about the problems that you have ben having in getting your pump. I have had problems with insurance company before, alsthough not in regard to my pump. The bottom line for me was what the DOCTOR wrote.
what he said and how emphatic he was and what reasons HE gave. Insurance comes recently have become mincromangaing their claims. I turned in one for an ambulance trip to the hospital whenm I had gone onto a coma (low blood supar - 13), and the first time it was supbmitted it was denied? They tried to say that I had another way to get to the hospital? After the ambulance sompnay went back to them with the details, my claim fiinally got paid, but ti took over 6 months. You probably need to see what was submitted to the insurance company so ou can "fillin"the gasp. Susan

What insurance do you have?

Hi Timothy
CCS medical is the supplier for my Animas pump also. They work for all the companys. But I am fighting Medicare just like you. They don’t even have to pay for my pump. My other insurance company will do that All thery have to do for me is to approve it. Like you I have had the laser surgery for the retinopathy and am already in kidney failure. I don’t know what else they want.


Check your plan for appeal procedures. many plans have an appeal process and now woudl the time to invoke it. the sooner the better.


Do men have to get pregnant for a pump? Is pump coverage stopped after the pregnancy?

Sad part of insurance is that they will pay for an amputation but not for the training and treatments needed to prevent that from ever occurring. I think most companies look at a member and say, by the time any complications show up, he’ll be on someone else’s policy… probably Medicare/Medicaid

Appeal the process. When they send you the actual rejection letter, it should contain a letter describing the process for appealing the decision. After you are done with the 1st and 2nd level appeals you would either appeal to the state or federal gov’t, depending on the type of plan you are covered by. You also have the right to request any and all documents from the insurance company that relate to your case. I think they have to provide those no charge, but I am not sure on that point. You have to follow the companies appeal process to the letter so they have no “extra” reasons to deny.

Most of the major insurance companies have specialists that can explain the process too you, try talking to one of those.

Good Luck