Durable Medical Equipment Question

I am in the process of appealing 2 claims to United Healthcare for my pods totaling $3400. I have been using the Omnipod since June of 2009 and had claim denials the last 2 shipments. UHC makes me go through Edgepark Medical Supplies and during the approval process my endo’s office, Edgepark and I spoke with UHC confirming benefits and approval. We were all told the same thing that once my $2000 deductible was met the pods would be covered at 100% not applying to DME. Of course this is nowhere in “official” writing and now UHC is claiming that the Omnipod falls into DME, which I have a $2500 cap on for 3 years. They can’t seem to grasp the mechanics of the Omnipod and insist that I cannot get a new insulin pump every three months. No kidding! Does anyone have experience with this, or actually won an appeal? Thanks! Karin

Unfortunately I just had to switch off of UHC, but I was in the same routine and never got any grief. Sorry I can’t help, but I’m sending good vibes your way…

What state do you live in? A DME cap of $2500 is ridiculous. You couldn’t even get regular pump supplies (for three years) for that amount.

I have Aetna, but my pods are covered under the DME portion of the policy (as were my Minimed pump supplies).

Years ago, when I got my first pump, I had United Healthcare. They covered the pump and all supplies at 100% with no deductible or cap.

Shannon, I know it’s totally crazy! I am in Wisconsin. Luckily, I have just switched over to my husband Aetna insurance which is much better already, but the UHC is still hanging over me.

Thanks for the vibes Todd!

I have a nice BCBS (NC) plan through a good employer and I can say that pumps and pump supplies (as well as CGM supplies) all fall under “durable medical equipment” on my plan. However, I have a $500 deductible for DME and after that it’s all covered at 100%. Sorry I don’t have anything more similar to your experience, but I thought I’d post anyway, just because I think sometimes it helps to just have a general view of what other plans are like. I do consider my health insurance to be a very good plan. I work at a pharmaceutical company of about 250 employees and the company puts a lot of money towards our health insurance each month.

My Omnipod stuff is also all covered at 100% under DME. I know that some stuff can go back and forth though because when I switched to the O-Pod my test strips started being covered under DME where as before they were prescription meds. I would think that UHC must cover site changes for other pumps though and my CDE told me that Omnipod pods were billed the same way as site change supplies for other pumps. I would definitely fight this and point out that if it only lasts 3 days (which is does!) then it can’t possibly be durable. I have Keystone Health Plan East which is a subsidiary of Blue Cross Blue Shield if you want to use any of my info in your appeal.

Mine have been considered DME under my last two plans.

I have UHC and get the pods through Edgepark it is DME but we have a $50000.00 lifetime Cap.

I have Golden Rule, which is the non-group insurance offered by United Health (I’m self-employed).

My Pod is covered the same as anything else on my policy (though it is considered DME). For my specific policy, once I hit the deductible, everything over that is covered 100%. I have a $3 Million maximum lifetime benefit, that’s for everything (prescriptions, doc visits, DME, etc).

I’ve had no problems at all with Golden Rule/UHC, but it all depends on the policy. When I talked to EdgePark (where I get my pod supplies) they told me UHC policies were either very very good, or very very bad when it comes to DME. So it’s not just the particular health insurance provider, it’s the actual policy that you/your employer buys. Unfortunately nowadays, lots of employers are trying to cut costs and buying the bare-bones versions of health insurance.

I also gave UHC, with the $2500 Diabetes cap. We met our $5000 high deductible and now I have the omnipod. I have not yet had UHC pay the first bill. I did not get the part of the 3 year issue. Wow, I hope that does not work like that. You have gotten me scared. I do know they told me that not only once I met the $2500 diabetes cap, anything above that not only would not be paid my UHC, but that what I pay will not go toward the $5000 high deductible amount.

I do not have a choice to move to my husband’s insurance and he is on mine as he has been self employed. It will bankrupt our family. I may have to go on MDI - which I have not been on since 1997.

I’m having the same problem with the $2,500 dme cap. Last year my pods were covered 100% but it appears that my policy now treats them as dme. I’ve spoken to Omnipod and they do maintain a list of insurance companies that treat the pods as supplies. They won’t publish this list but if you call on a specific insurance company policy they’ll be able to tell you how it treats pods. Edgepark charges $300/box (contracted rate) compared to $365/box if you buy directly from Omnipod, so for me it makes sense to continue to purchase through Edgepark. According to Edgepark, “about half the insurance policies treat pods as dme”. I’m in Rhode Island and am looking to see if there are any laws that deal with insurance company non-discretionary obligations to cover diabetes supplies (as I consider the pods as supplies not dme). I thought my UHC policy was top notch but I guess that’s changed…Sorry I don’t have any good news. I will consider filing an appeal based on what I find out from my review of RI law.

My insurance policy is changing this year too (Keystone Health (a BCBS company)). They treated pods as DME but covered 100% until this July when suddenly they’re only going to cover 70%. I feel like my insurance is going from one of the best to one of the worst overnight. I think many insurance policies are taking a hit this year.

My UHC premium was $75/payperiod for the employee portion for employee and spouse. Now come July 1 it is going up to $183/payperiod. I do not know WHERE I am going to be able go come up with this money…:frowning:

Oh man, I’ve been away from Tudiabetes for a while! Thanks for all the responses.
Since I last wrote, I have appealed and WON, claims totaling over $4000 with UHC. It took countless hours on the phone, mostly getting transferred back and forth, and several letters to UHC. I work for a small non-profit (advocating for people with hemophilia and their health insurance issues go figure) and we have terrible insurance. I think only 3 of 8 employees are now on the bargain bin insurance they offer.

I have now changed to my husband’s Aetna insurance plan. He is a public school teacher and has excellent benefits! Unfortunately, they are laying off 250 teachers next week and it is looking like teachers not let go will have to switch to a different plan for the district to save costs. So, who knows in a few months…

Pardon me while I vent. Don’t the *&%( insurance companies realize it is cheaper to pay for pump supplies than visits to the ER because of poor control on MDI?

I know, it’s a stupid rhetorical question. I just had to say it. I have a good Aetna policy through my wife’s employer and after my deductable everything has been covered 100%. Last year I had met my deductable before going on the Pod, so the PDM and pods were covered 100%. This year I met my deductable before my first reorder, so again the pods were covered 100%. I sure hope we don’t have to change insurances!

Hi there! I am going through the exact same thing you did. I have already put in an appeal through UHC, but have not heard back from them yet. What direction did you go that let you win the appeal? That is should be consider supplies not DME? I guess I’m probably going to have to appeal again if this one doesn’t go through and would like a little input as to what you sent them in your appeal. If you can email me at aburkert@mainscape.com I would really appreciate it. I just signed onto this website in order to reply to you so I’m not sure how I would check if you responded. Thanks again

Amanda

IMHO some insurance companies and our own government (Medicare) would rather pay for an amputation of a limb than to pay for the technology available today that may help prevent the problems in the first place. Very sad commentary on health care in the U.S.