This might be a dumb question, but I know how supportive the TuDiabetes community is, so I’m throwing it out there:
I want a pump, but how do I get one?
Right now I inject insulin manually (is that what you’d call it?!). I inject my basal insulin (Levetra) in the a.m. and p.m. and I bolus (humulog) every time I eat.
I’ve heard a lot of you here on TuDiabetes and on Twitter talking about getting approved for a pump through your insurance company. And I’m so curious, how do you get started on that process?
I haven’t seen an Endo yet. Keep in mind that my health insurance just started covering diabetes May 1st, so in the past two years I’ve tried to survive seeing nurse practitioners (when I was paying 100% in cash) and family practice Drs (when my insurance covered everything but diabetes).
Someone give me some advice.
What makes someone a good candidate for a pump? What are some reasons that a health insurance company would deny a pump “prescription”??
I’m about to try to do the same thing as far as a pump goes.check out this link below its basicaly what my endo told me I had to go thru and to also plan on about 6 months to get it aproved,but I figure might as well start now.
First look at the pumps you may be interested in… I then told my endo what I wanted. I went to the website of the chosen pump, found the forms (should be listed as get started or something similar) filled out my part had my endo fill out their part faxed the company my forms and insurance card and I had my pump in about a week, it may take longer depending on your insurance.
At the time I started on a pump, the MiniMed was the one my doctor’s office and diabetic center was most use to. I contacted the company by phone and they sent me all the info I needed to fill out. When I switched to the OmniPod, it was the same situation. In both cases, I was approved in about 1 week. What my insurance company looked at was if you were doing multiple injections a day, how your a1c is, and doctor’s recommendation. My doc pretty much has a form letter that they use. I was able to fax my filled out forms, and it was rather easy. You probably will have to chose a pump first. You have to want to get better control of your blood sugars, watch your carbs, and test, test, test. If you have that desire, the pump is great.
I’d start researching the pumps and reading the reviews of other using them so that when you talk to the Endo you already have some idea what you want and why you want to switch from MDI to an insulin pump.
I’d probably have my decision made before seeing my Endo but I’m a little over-organized in that way
As far as getting one, from what I understand it has gotten easier over the years to get approved for a pump although I’m sure that varies a bit from person to person, company to company.
Right now insurance companys seem to delight in telling us NO for CGMS but insulin pumps are becoming common practice for T1s so its a bit easier to get approval.
You Endo’s office will more than likely be very well versed in what needs to be done, what info needs to be submitted etc.
I’d make sure when you go to your Endo you bring all prior test results A1c’s etc from whoever you’ve been treated by for the last few years.
I was wondering the same thing before I got my pump. I took the lazy approach and let my endo choose for me and had the Medtronics (the makers of the pump he prescribed me) handle my insurance company. They must be very sweet talkers over there because I was on that insurance for barely a month before I asked them (through Medtronics) to cover a $6,000 pump plus supplies plus CGM. I personally hate insurance companies and consider them all to be pure scam artists in one of the last legal scams in this country, so knowing that they are losing massive money on me right now makes me grin every time I think about it.
My endo at first just gave me the RX and I went to a pharmacy to fill it. After visiting every pharmacy within a 2 hour drive I finally got on these forums where I learned what to do. In the end I had my endo fax the RX to the company and they called me to set everything up.
My endo also put me on a different insulin regimen to convince the insurance company that I was in need of a pump so they would cover it (see? scam artists!).
In 2004, my insurance denied my pump, until my doctor said that it was medically necessary to prevent nighttime lows.
For insurance companies, the threat of severe hypoglycemia is a motivator to pay for anything. So be sure to have your doctor mention that you have lows (we all do…).
I think that the most important thing is that the insurance company sees that the pump could prevent hospital visits or ER visits. These are immediate expenses that they also want to avoid.
Also, it’s possible that a certain pump company will not be in the provider network of your insurance company. In this case, you are asked to pay a large out of pocket expense, BUT this is not necessary!! Just find a distributor company that you can buy the pump through. For example, I would have had to pay $800 for my Cozmo pump if I ordered it straight from the company. By ordering through an “in-network” distributor, I avoided this cost. Just wanted to write about this in case this happens to you too!
If you’re a T1, getting approved for a pump should be fairly easy… you’ll probably need the Rx to come from an Endo or an Internist though… so seeing one of those would be the first step towards getting a pump. Once you are established as a patient, then you can begin the process of getting the insurance approval through the pump company of your choice.
You gotta go to an endo ASAP. They write and RX to the pump company once you decide which one you want. I suggest asking the endo what kind of relationship they have with the pump reps to see if you can get a loaner to try multiple pumps. The doc will also have to fill out paperwork for the insurance company proving medical necessity for the pump. This will be no problem for you since you were just in the hospital due to DKA.
What makes you a good candidate? Being T1 or T1.5 is a big reason. Alot of insurance companies fight giving pumps to T2s for some reason. A desire to bring down your a1c is another reason you would be a good candidate. Doing MDI (more than 2 shots a day) helps you case. Having problems with crazy blood sugar trends helps. I actually got turned down the first time I asked for a pump because I only did 2 shots a day and I hadn’t been hospitalized due to BG issues!
Why would they deny you? They don’t want to pay the upfront cost. They may have a policy that they always deny people the first go around to see how serious you really are about a pump. They may want to be sure you are seeing an endo for a certain amount of time, like 12 months, before they OK it. They want to make sure if they buy you this expensive piece of equipment that you will actually use it and see the endo like you are supposed to. They may want a 3 to 6 month records of your BGs to see if you really are out of control so if you don’t have this, they say no. It all just depends on how your insurance policy is written.
I am sending you positive thoughts and wishes that your insurance company is one of the cool ones that says OK just because the endo said it was medically necessary
Most won’t deny you especially if you are MDI treatment mode. In my case, my c-peptide level was 0.5 which is below the threshold combined with 4 shots a day. This indicated I am producing very little insulin on my own. That sold the pump for me to BCBS. My bigger fight was the monthly supplies getting reimbursed. Fortantely, I won my appeal and it’s 100%.
