I'm wondering if someone could help me here. I am trying to get approved for a pump, I am on Medicare. I was diagnosed about 10 years ago as a type 2 and have struggled to get control of my sugars. My doctor wants me to be on an insulin pump because she thinks it will help me. I was approved for an omnipod before I started Medicare and had to stop because the supply company thought that my c-peptide was too high (2.64). I am trying this again, here is my info:
C-Peptide: 1.9 (0.80-3.10 ng/mL) Fasting sugar at the same draw: 164
A1C: 12.7
I take 100u of Levemir in the morning and at night I take 60u of Novolog with meals
The rep from the company that would be supplying my pump said that my c-peptide might be too high. I am so depressed right now. I cannot afford to keep paying for my insulin, I'm in the doughnut hole now. Any help interpreting this would be greatly appreciated.
I am going to let other Type 2's respond about their experiences with the pump and Medicare. I do know that having already been on a pump will help. Also your doctor can write a letter of necessity describing why he feels you should be on a pump for your care, and your high A1C certainly will help.
But I do want to say a bit about pumps in general. They are incredible tools and I am very grateful to have one. But they aren't magic wands. There are certain skills you need to have to utilize a pump and they are the same skills you can acquire while still on MDI. For example, being accurate at counting carbs, and utilizing the standard of care of an Insulin:Carb ratio for your meals, not a set dose. Also knowing correction factor to correct highs and testing frequently and with purpose. A good source for these skills is the book Using Insulin by John Walsh. He also wrote Pumping Insulin which is great to apply all the skills to using the pump to full advantage.
Again, I don't know the specifics of how hard or easy it is for a Type 2 to get a pump on Medicare; there are many Type 2's on here with pumps but I don't know how many are on Medicare. But I do know that if there is a question about coverage of a pump they are going to look at two things: Need and Ability to benefit. So my suggestion is to work with your doctor to develop a letter of necessity and work with your doctor and on your own initiative to up your skills so you can use the tool to its maximum potential.
Thank you Zoe for your reply. I'm getting so depressed and frustrated with all of this, I feel like it's a losing battle for me at times. I want to stay positive but it seems like there's not much I can do. If I don't get a pump then I don't know how I will be able to afford to keep buying my insulin. Maybe someone here has some suggestions, I know I cannot be the only one in this position. The price of insulin is crazy.
I do try and stick to a good carb ratio, though at times it seems like it doesn't matter. I was just in the hospital a few weeks a go were they were watching my carbs closely and giving me huge amounts of insulin. The nurse even commented that they never give this amount. My doctor came in the next day and questioned if the nurses were giving me my insulin because my blood sugars were so high.
I should also say that my doctor believe that I have Cushing's Disease because I have tested positive in a number of the tests, but it's a hard thing to get a final diagnosis. This is why I believe I have such a hard time with my blood sugars.
Sorry if I'm rambling, I just do not have anyone that I an talk to that would understand!
Leslie65: Has your doctor ever tried to prescribe U-500 insulin ( type 2s who are knowledgeable, please chime in) It is an analog insulin, I believe, such as Humalog, that is concentrated in a manner that its potency is up to 5x that of u-100 insulins? It has been used effectively on MDI regimens for those who are highly insulin resistant. Because it is super-potent, you do not have to take as much per dosage.
I also agree with Zoe that set dosages for meal coverages may not lead to the best outcomes. Do you use an exchange system or count carbs? Do you eat exactly the same amount of carbs for each meal? I tried that exchange system and same amount at every when I was diagnosed as a child at 13 almost 47 years ago, and I can tell you, it was and is hard to do.. I far prefer to count carbs and adjust according to what I am going to eat.(moderately low carbs)
Additionally,Do you use a sliding scale to correct your own high blood glucose levels, or do you have an insulin sensitivity factor that you can use to know how many units of insulin is needed to lower your blood glucoses? The books that Zoe recommended have useful information as to how you can learn to do this yourself. If you are, as you appear to be, highly insulin resistant, you will need specialists in an informed, flexible team who will work with you on a personalized treatment program. I am not familiar with Cushing's disease, or its effect on blood glucose levels. Maybe others here can help.
Is your doctor an endocrinologist or a GP? It sounds like that your medical team needs to help you get a handle on how to manage your high blood glucoses prior to putting you on a pump....As Zoe mentioned, a pump is a very incredible tool, but you have to have the proper information programmed into it, and the proper skills to manage it in order to make it effective. Does your doctor have experience in prescribing/treating type 2 diabetics on pumps? Just asking so you can know where to turn to get the best treatment. University Medical Centers often have the most up to date information and may have reduced fees or payment plans for pump evaluations. I hope you start feeling better and receive the type of care and attention that you need.
I think you should call Medicare directly to answer your question. From what I have read it is your doctor who prescribes the pump based on the need. I recall that Omnipod was not an approved pump at all for Medicare - but don't know if they have been successful in changing that. Your insulin needs are incredible so I can understand your depression. I am sure that reps for supply and pump companies know a lot about getting pump and supply approval, but you should get the facts from Medicare.
Here is what Medicare says: Insulin pumps worn outside the body (external), including the insulin used
with the pump, may be covered for some people with Medicare Part B who have
diabetes and who meet certain conditions . Insulin pumps are considered to be
durable medical equipment . “Durable medical equipment” is certain medical
equipment ordered by your doctor for use in the home .
How do I get an insulin pump?
If you need to use an insulin pump, your doctor will prescribe it for you .
Note: In Original Medicare, you pay 20% of the Medicare-approved amount after
the yearly Part B deductible . Medicare will pay 80% of the cost of the insulin
pump . Medicare will also pay for the insulin that’s used with the insulin pump .
For more information about durable medical equipment and diabetes supplies,
visit Medicare .gov or, call 1-800-MEDICARE (1-800-633-4227). TTY users
should call 1-877-486-2048
What those "certain conditions" are is the question I'd concentrate on. I also like Brunetta's suggestion regarding U-500 insulin. That is an option, but still a small fortune to pay out of pocket. The possibility of Cushing Syndrome is something to get answers for, it most certainly can cause havoc in managing your diabetes. May I suggest you insist on answers to this - getting treatment for this condition is not less important!
I wish you well. We can't fix any of this, but we can listen when you need to ramble.
I'm confused, Leslie, you said if you don't get a pump you can't afford to stay on insulin. You still need insulin for your pump! Do you mean because on the pump Part B will pay for it? For me, that has made my insulin free, compared to before when I paid a co-pay
I am also on Medicare. I was told Medicare does not cover the Omni Pod. This came from the local rep. They do pay for the other brands of pumps. I have a Animas PING and an switching to T:Slim. Medicare requires a 5 year warranty on the pumps it pays for instead of the standard 4 years. They also pay for pump supplies. Insulin is paid for under MNedicare Part B not D. If you have a Medicare Supplement plan there should be no out of pocket expense to you. Ever since I started on Medicare they and the Supplement have paid the full cost for supplies, pump and insulin. This assumes you are on original Medicare. If you are on a Medicare Advantage plan it all depends on which plan you are one. Technically they are supposed to cover the same things Original Medicare does. So if you are on Medicare Advantage please call their home office and talk to someone knowledgeable in claims.
I volunteer with SHIP (Senior Health Insurance Program). We provide no cost, no sales counseling to seniors on Medicare. I have saved many people money by getting them in the correct plan for their situation and offering advice about how Medicare works. SHIP is a Department of Insurance division here in NC. Every county in the country has a SHIP program. Some are better than others. SHIP was started in NC and is basically the flagship program in the country. some placed it is found under Resources for Seniors programs in some areas.
You are correct about the C-Peptude test, but I am not sure what the cut off number is. It sounds like your Doctor is a pump advocate, so a letter from him indication you circumstances may help. He will have to fill out a form for Medical need to go with your pump application. The pump company sends that to him after they receive your application.
I hope this helps. Good Luck.
LBREP
Just a minor correction here. It is my understanding that Medicare will replace a pump after 5 years but they have no control over the warranty. I had a pump for 6 years on Medicare and it worked fine in the 5th+ years but it was not under warranty after the end of year 4. Just saying. Medicare will replace a lost or damaged pump during the 5th and unwarranted year. This is what I was told about 3 years ago so I don't know if that has changed but I am certain about the warranty issue. But pumps don't "die" at 4 years and one day! They can keep going quite a while.
Re Leslie-- it sounds like you need a good endocrinologist. I don't like the sound of your dr's approach. Just my opinion.
I hope you can get approval for your pump even if you have to change it. You need your doc to be your advocate here and write a letter of medical necessity. I don't know what the levels are for c peptide for pumps but maybe that can be overridden and the fact you have cushings can probably help. Maybe there are programs that can help pay for the insulin. I think there are a lot of programs with the manufacturers which help, I used one to pay for my copays for a several prescriptions with novolog. They would only pay for novolog or levemir though not both but that was just a copay reimbursement program. The link below says if you meet the requirements you can have only $25 copays for those insulins.
Hello, I'm in the same boat. a I am also a type 2. Just dropped off my paperwork today and hope to hear back soon regarding coverage. I'm hoping for the Animas Ping, but would be happy with the Tslim and an Omnipod as my last choice. I hear you about Medicare! Have you heard anything?
News I just received from a Tandem District Manager 1. Medicare CGM Access Act of 2014 introduced in the Senate - Today, Co-chairs of the Senate Diabetes Caucus, Susan Collins (R-ME) and Jeanne Shaheen (D-NH), introduced the Medicare CGM Access Act of 2014 (S. 2689) – this is a big win. Though the bill is not yet posted online, it would create a Medicare benefit category for CGM and establish a payment and coding structure to go along with it. Notably, the bill has been drafted to pave the way for reimbursing future artificial pancreas technologies. There is certainly lengthy road ahead before this is passed into law, but the move is highly encouraging and desperately needed from a patient perspective. We were very encouraged to see the collaboration behind the legislation – the coalition that has worked on this issue includes JDRF, the Endocrine Society, AACE, AADE, Dexcom, Medtronic, and J&J. JDRF was out in full force on the news today, including a press release commending the bill and two advocacy asks: emailing US Senators to co-sponsor the bill and signing a petition to urge Medicare to cover CGM (the latter is at an impressive 3,845 signatures already out of a goal of 10,000). Completing both tasks takes less than five minutes! For more on this topic, including why Medicare has refused to cover CGM, see our detailed report.
The Do ought hole is going away in 2017 I believe. If you are not already doing so, please review your Part D plan during each Open Enrollment Period Oct 15 to the end of November I have been on Part D for 7 years and have changed plans in all but 2 years. Each year the companies formularies change, premiums change, co-pays change. This will allow you to compare all the plans available in your State. You can do this on Medicare.gov
Unfortunately Medicare does not cover Type 2 diabetics. Hopefully that will change. Keep in mind that even though insulin can be expensive, it is a lot cheaper with Part D that what we had before that, which is nothing, I do not know what your income is but if it and your assets are below a certain point you may qualify foe your states Low Income subsidy I do not know what tour States qualifications are but you can check with your local Senior Health Isnsurance Information Program (SHIP) This is typically a subsidiary of your Dept. of Insurance or your local Resources for Seniors program could direct you there. Good Luck
I don't think it is true that Medicare does not cover pumps for T2, they just have a separate set of somewhat discriminatory criteria. And of course each state is separate, but the national coverage determination allows a pump for a T2 if:
Meet the updated c-peptide requirement:
Insulinopenia is defined as a fasting C-peptide level that is less than or equal to 110% of the lower limit of normal of the laboratory's measurement method.
For patients with renal insufficiency and creatinine clearance (actual or calculated from age, gender, weight, and serum creatinine) ≤ 50 ml/minute, insulinopenia is defined as a fasting C-peptide level that is less than or equal to 200% of the lower limit of normal of the laboratory's measurement method.
Fasting C-peptide levels will only be considered valid with a concurrently obtained fasting glucose ≤ 225 mg/dL.
Levels only need to be documented once in the medical records.
And you also need to either be grandfathered by having a pump before enrollment to Medicare or demonstrate what is essentially poor control
Glycosylated hemoglobin level (HbAlc) > 7.0%;
History of recurring hypoglycemia;
Wide fluctuations in blood glucose before mealtime;
Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl; or,
History of severe glycemic excursions.
What is really sad is that Medicare coverage for pumps for T2 is focused on giving pumps to patients who may not be in the best position to actually benefit and achieve the best outcomes.
Medicare supplemental insurance has been essential for me. The pump has been covered, and supplies also. I have had to struggle to get the insulin charged to Part B, as it should be when used in a pump, and not put me in the Part D "doughnut hole" in February. Getting the insurance company to fight for you and not with you is key.
If you have a Walgreens, go there. I get mine there and they are all set up to run it through Part B… Sometimes when I pick up and order they want a co=pay but I remind them to run it through the Supplement and that brings the cost to 0.
I am now getting the insulin at Walgreens, as they can charge it as a Part B. I am not sure if it is being processed that way, as now I get some coverage through Medicaid. The advantages of collecting multiple auto-immune diseases.
Leslie, I'm (we think) a T2 and I qualified for a pump on Medicare, but I almost didn't. My first C-peptide test came out too high. One thing a fellow diabetic told me (a T1 also on Medicare) is that if your blood sugar is high when you take the C-peptide test, then your C-peptide will come out higher. My first C-peptide test was taken on a morning when I had been sick the night before, and my am bg was in the low 200's. I had it retaken a few days later when my am bg was below 80, and my C-peptide was then low enough to qualify for the pump.
I often times think medicare doesn’t know what it’s doing. I was on a pump for 8 years, then it went up and medicare wouldnt replace it. Said my c peptide was too high. So went on shots, that didn’t work so well my sugar levels were all over the place. So we bought one on our own through my Drs prescription for one as she thought I really needed it ( she’s been fighting for me for over a year). Anyway, medicare won’t even pay for the infusion set or the reservoirs that I need for the pump. In fact, when I went to get the supplies I needed for the pump made by Medtronic, I can no longer get them thru Medtronic or Uof M or even ADW. They have stated they no longer bill medicare. I have to pay out of pocket for the supplies. All of these companies told me to contact medicare to see what companies i could get supplies where medicare could be billed. So I called and the medicare person who talked to me told me to contact Walmart, Rite Aide and some other pharmacy. Now, I’m not exceptionally smart, but I’m far from stupid. I knew these places do not cover insulin pump supplies. How are we suppose to get honest answers on medicare coverage for pumps when people who are working at medicare.gov don’t even know what your talking about. Im still fighting to get medicare to pay for my supplies and eventualy my next pump. I just don’t understand if a patient is doing exceptionally well on a pump and has done for 8 years or more, why they would you change the rules and play with the patients well being. My Dr is doing her part, I’m doing mine and Medicare is dropping the ball.
Your problem is your doctor is NOT doing what needs to be done to get Medicare to cover your pump. I ought to know–I watched for a few months as our very pro-patient endo (he is SO good at getting things covered that are “on the edge” unlike some previous docs we had) worked with my wife to secure her Medicare coverage for her pump. The issue, somewhat similar to yours, was a too-high c-peptide. JUST over the limit. So he had her take additional blood tests and when that still didn’t satisfy Medicare’s stringent rules, he went with an old standby,“she needs to pump because she has severe hypos, uses TINY amounts of insulin, yada yada yada”. It’s all about YOUR endo knowing how to PLAY THE GAME. If you cant get what you want thru your doctor, SWITCH. It is up to the doctor to help you out. OUrs has done such things for my wife for many years. I wish everyone could go to one like him. I’ve been to some real clunkers, which is WHY I SWITCHED.
