I got denied for a pump but not for the supplies.... Need advice

Hi all,

last year, I decided to get the pump for several reasons. My endo was super supportive as she didn’t like the amount of hypos I had.

We submit the request through Edgepark. After verification with my insurance, they called me to inform me they could ship my pump at a cost of $x. In August (yes 10 months later), I got an email from them telling me I owed them 4k. It appears that my insurance had denied my pump and that their appeal failed. I never realized that I was not covered as all my infusion sets and cartridges were approved and covered by my plan. Is that common?

I appealed without knowing what documentation to provide. I thought that my endo letter and some data (my c-peptide, few CGM graph showing my hypoglycemia) was sufficient. I just got their denial stating that I didn’t assist to a educational class, that I failed to show that I test 4 times a day and that I failed to show that I have recurrent hypoglycemia. Well, not sure how to fix the first statement. I was 26 at the time of diagnosis and I learned so quickly with internet and few books that I didn’t go to any class. As of the rest, I could have easily proved it. Now I can do a final external review. What do you guys recommend? Should I consult a lawyer to be sure I have all covered? As for my supplies, with my recent appeal, are they gonna figured it out and stop paying?

I have to say, Edgepark (and your insurance) messed up. From what they say you were preauthorized (presumably that was the “verification”). They then shipped you the pump and the supplies and then in August decided to reverse their coverage decision. There are no takebacks. They cannot retroactively undo their positive coverage decision. Have they actually told you that you need to pay for the pump and the supplies?

You may have to struggle with their decision to not cover you moving forward. But if you closely examine the policy you should be able to figure out their requirements and meet them.

As to the bills, Edgepark has a responsibility for not performing due diligence. They should have obtained preauthorization and taken the lead in navigating this problem.

Your insurance company is using Medicare criteria to approve or deny your pump. Those are what I had to prove to Medicare in order to prove that it was necessary to continue using a pump when I first went on Medicare. Medicare did not pay for the supplies either. If you can, you need to appeal the insurance company denial and provide for them all of the info that they are asking for. You may want to ask them for a copy of the guidelines that they are using so that you are able to submit everything they are asking for. Good luck to you.

If these are their reasons for denial, it should be a fairly simple fix.

  1. Attend a pump class. Your endo should be able to set you up with one.
  2. Log sheets should show the number of times you test per day. We’ve always been required to furnish 3 months of logs with the other paperwork.
  3. Those same log sheets should show your lows. While their definition of “recurrent” may not be easy to pin down (you can sometimes find it by searching requirements for pump approval in either the benefits booklet or online.) Quite honestly, I know my daughter has recurrent hypos because she’s T1 (duh), but to prove it on paper required a bit of editing of the logs.

I would do all of the above before submitting another appeal.

The best thing to do in an appeal is request from your insurance company a copy of their medical policy for determination of coverage and also appoint (you will need to do this through your insurance company) your endocrinologist to act on your behalf in the appeal. Doctors many times can make a much stronger argument this is really a medical necessity denial so your doctor HAS the right to do a peer to peer review and speak with the medical director of your insurance company. I agree I’d also look into maybe contacting Better Business Bureau and file a complaint with Edgepark. Also your Board of Insurance. Your health insurance company is supposed to notify the doctor, providers and patient of any denial…medical necessity or benefit denial so that doctors/patients can do their reconsiderations, peer to peer reviews (options for the doctors) and appeals (options for the patient) and the time frames for doing that.

Hi Brian,

indeed Edgepark really messed up. They told me my co-pay and I paid it. Weirdly, 15 days or so later, I got reimbursed. I went to their website and I saw that indeed, it cost $0. I didn’t have the time to look into it and like I said, the orders after went through. What I learned after is that Edgepark was appealing my insurance decision without telling me. On BCBS website, it was showing very clearly that they denied it in November 2015. The only communication I got from them was the standard e-mail saying I had a new claim (which I usually don’t look ->not anymore :frowning: I definitly might need a lawyer just for that…

I got the pump training by tslim but never had educational class for diabetes management. In my letter, I did say that I went to see a diabetes educator and a nutritionist after my diagnostic. I can’t believe everyone goes to class…have they heard about self-learning and oh … google?

I would not leap to retaining a lawyer. That can cost you money which you don’t need to expend. I would basically take the position that this is their mistake, you won’t be subject to possibly illegal balance billing but you would be happy to work with them to get it through their strange and demented approval process.

Typically, a provider (such as a pump manufacturer or DME company) will navigate this process. Pump suppliers have become very sophisticated in doing this properly. You might even consider enlisting tandem (the maker of the tslim) in untangling this mess. But I wouldn’t spend a penny on a lawyer and I wouldn’t pay any bill that represents balance billing. I would actually ask Edgepark for the “preauthorization” and use that to argue that it isn’t your problem.

ps. I successfully got a copy of the preauthorization and I had a similar problem of charges for denied coverage magically “go away.”

It depends in the insurance requirements, & sometimes the Endo. My daughter was required to attend a pump class by both, & then we paid OOP because insurance denied it as an uncovered expense.

Google is a great tool for finding info, as long as you’re able to sift through the results. There’s a ton of bad info online.

I agree that you should fight Edgepark over the bill, but I would also provide the required documentation outlined in the denial.

Small update. I had a meeting within my company to comment about the new measure from my insurance company (total coincidence). I was able to have extra help from them and learned that Edgepark never submitted any paperwork prior to shipment of my pump. It’s weird. They always says thing like: “Oh there will be some delay. We will verify with your insurance for coverage…”.

As for the process, my doctor was doing a peer-to-peer review today. I’ll move to an external review if it doesn’t go through.

Hope it all works out for you. Oh wow, someone really dropped the ball and Edgepark and screwed up. That really is on Edgepark if they shipped prior to obtaining the approval.

The story had a good ending after all and I want to share it so people that end up in my situation doesn’t get discourage. The peer-to-peer review failed (which was a first for my endo). They told her I was too good of a patient. I had to go to an external review which finally allowed me to provide the appropriate documentation. Although my A1C is in the range of 5.3-5.7, I wrote a long letter about why I changed for the pump and why it was a better option for me. I backed myself up with graphs, BG logs and simple I:C calculations (my insulin requirement varies greatly). Also, I showed that I purchased books about diabetes management and had meetings with a CDE and a nutritionist. Not sure what convinced them but I succeeded. My take away message was that my Endo was too busy (and convince that the pump was an obvious choice) to convince them. I built the case on my own and went to her office to take the data I needed to prove my point.

I wanted to thank you all for your support.

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