Insulin pump denial

Diabetes Technology Insulin Pumps
1

Hello. I'm new to this site...came here because I need some advice/direction. I was diagnosed with Type 1 diabetes 4 years ago. I did a ton of research and decided pretty early on that I wanted to go on a pump. I remember reading (back then) that part of the requirements to get a pump was to be able to demonstrate competence and discipline in managing your diabetes with MDI. I've done that this whole time. My most recent A1c was 6.3. I've actually managed to keep my A1c between 5.7 and 6.3 for the last 4 years! However, that comes with a lot of work (and honestly with a lot of lows too). I check all the time though, so I've never passed out or anything. Excercise, even just walking, will usually send me down. I have a lot of swings too sometimes from high to low. (I'm on lantus...tried levemir a short time and that worked better for me, but my insurance doesn't cover it!) My job complicates things too often because I have a crazy job with a crazy work schedule at times. Planning for anything, even meals, is pretty tough due to my job. And once you add my 1 and 4 year old kids to the mix...well...lets just say I'm convinced that the pump would make diabetes management so much easier for me.

Anyway...the trouble I'm having is that I have not been able to get approved for an insulin pump. In 2010, I was told that I was approved (was with Blueshield then), but was responsible for 50% of the cost. I couldn't afford that so in 2011 I switched to Cigna. That year I tried again and was denied by my medical group, not Cigna, because they said I didn't meet "Cigna's criteria" of having an A1c above 7%. So...2012 I switched to United Health Care. I spoke to several people from United Health Care and reviewed their criteria on line and there was nothing about needing an A1c above 7%. This time, my request was "withdrawn" by my medical group and I was told to first meet with the CDE so that she could determine if I should be recommended or not. I had met with her multiple times in the past and she always pushed for the pump for me. I was sure she would make the recommendation. When I met with her last week though, she said that a week earlier she had a meeting where she was instructed not to recommend anyone with an A1c below 7% for a pump. So I'm at a standstill again! What's odd though is that in 2010 I was approved even though my A1c was below 7%. I mentioned this to my CDE and she said that "maybe the rules changed."

My question is, is this A1c rule my medical group is insisting on a standard for everyone? Has anyone on here with an A1c below 7% been approved for a pump? Any ideas as to what I can do? Would changing to a different medical group make a difference? Any ideas/help with this matter would be GREATLY appreciated! (btw...thanks for reading my long long post!) :)

2

That is complete and utter nonsense. I have heard people say both "I was told my A1C was too bad for a pump" and "I was told my A1C was too good for a pump." I don't know any facts about it, but no, I seriously doubt 7.0 is a universal standard. I basically think most doctor's don't have a clue about pumps and come up with their own standards. (Someone will correct this if I'm wrong). I had a 6.5 when I applied for my pump and was given it. (I have Blue Cross and my coverage for DME is 80%).

If I were you, I would do some pushing to challenge that arbitrary rule. A1C is only one factor in determining if a pump is appropriate and imho the least important. Yes, I would question someone with a very high A1C from getting a pump because I believe you need to have the basic skills of D management down to benefit from a pump and a very high A1C may indicate this is not the case. There are a lot of reasons to get a pump and many of them are not strictly medical, which is probably where the problem comes in for physicians. You sound like someone who could greatly benefit from a pump in how it will ease your life.

I don't see an endo and my PCP knows very little about Type 1. So I didn't start there. I went right to Animas and they did all the work for me, contacting my insurance company for approval and then putting the form in front of my doctor to sign. I think they are more motivated than the doctor because they make big money on every pump (and the subsequent supplies). You might want to try that approach.

Finally, if you run into a total brick wall, yes, I would look elsewhere for your care and see what their attitude is to pumps. Any endo who stays current should realize that a pump is the current standard for care for Type 1!

3

Oh honey! That's such a run around. I don't really know much, but I would think your doctor could make a writ of necessity and push that through! I get so frustrated for people who end up doing all the leg work and paperwork and pushing and pulling... grr. But, in the end, I think whatever company you go to should be good at helping you get the pump. I know with Minimed, they know everything about who covers what and for how much and what hoops they are going to have to jump through. I would start there. Let the professionals handle it. Maybe that will work.

I was anxious about coverage when I went in for the CGMS. And i heard all the things you hear about the pump... needing high A1cs, as if a lack of control would be the only reason a person might need the technology. BUT, I am a mom of 5 kids with a husband who is often away. I wanted the security of those sugar trending alarms. Still, when I did get the CGMS, I had people ask me if things "were really that bad." *eyeroll* oh well. What can you do?

4

Empire BCBS approved my pump in 24 hours. My A1C is a lot higher, 8.7, but I had been on prandial insulin only a very short time. Animas did all the legwork. I filled out a form and talked to one of their reps, and presto, I was approved pending doctor's authorization. Maybe you should approach the problem via the manufacturer of your presferred pump?

I should mention, however, that my endo did not like that I did it this way at all. She suggested the pump, wanted me to think about it for three months and then get a Minimed Paradigm. I did quick and thorough research, and decided that Animas was the way to go, and got the whole thing done a week and a half after she suggested it. She was cranky when Animad called her office all of a sudden, requesting an authorization, but seems to be adjusting.

5

It sounds like the denials you've been receiving are totally arbitrary. The realty is that the insurance company doesn't want to pay for the pump! I believe that if you persist, you will be successful.

If you have "dawn phenomena" then perhaps your doctor writing that current basal insulins cannot match the pump's ability to customize your basal insulin needs in the early morning hours.

To answer your question, my A1c was in the 6% range when I was first approved.

I echo the advice you've already received to let the pump company's insurance specialists handle all the details. Good luck! I wouldn't want to go back to multiple daily injections -- I've been on insulin pumps for 25 years.

6

Hi -

The behavior of the insurance companies is shameful and your medical team is spineless (or worse). Start documenting all your lows and request a letter of medical necessity based on frequent hypoglycemia. If your docs won't push for you on that basis you really need new doctors because they don't have your best interests at heart.

Maurie

7

I think you are getting a run-around. Your A1-c is well within the normal limits to approve a pump. What I am wondering about is your approach. To get a pump, you need an endo who will order a GAD 65 test to affirm the presence of anti-bodies. Beyond that, you must affirm through your doctor or CDE that you understand the principles of carb counting and diabetes management. these goals are usually fulfilled by a couple of meetings with a CDE. Finally, you need to choose the pump that you want. From there, you need to complete the application form and have the pump company do the work with the insurance company.

No doubt you will have some co-pay, but there should be some positive dialog between, you your physician and CDE and your insurance company to get the approval that you need.

My pump was denied once, because I was told I didn't meet the criteria for approval. The second time, we had a whole different set of tests and totally different circumstances. (I moved from a type 2 diagnosis to LADA.) My pump was approved with little problem. Animas did all the work. A should have sent flowers to the Animas rep.

I couldn't be more happy with my pump. I have had wonderful service from Animas and their customer service, and the training was wonderful. they will do all the work for you.

Be well.

Brian Wittman

8

I'm so happy to see so many responses! Thank you all.

Just a few things...

I did have the GAD test done 4 years ago which is how they determined I was Type 1. Also, I don't have an endo and my PCP knows nothing (in my opinion) about Type 1 Diabetes. He initially put me on Humalin 70/30 (which was a mess) and had only written a prescription for 2 strips per day! With the CDE's help (and my push based on research), we got him to switch me to humalog and lantus and 300 strips per month (recently reduced by my insurance to 200 strips per month). My doctor has NEVER looked at my meter, logs (which I no longer keep, but will begin), etc. He has no understanding of carb counting either. I basically self manage, which has worked for me, but I realize now has hurt me too because other than my A1c, my doctor has nothing to show medical necessity for me. My CDE has a lot more knowledge of diabetes and how my body works and she always pushed for the pump for me...linked me up to pump reps and everything. I really thought she was my ticket to me getting a pump, but when it came down to it, she couldn't do anything either because the medical group wont allow her to recommend someone with an A1c below 7 for pump therapy. In case you're wondering, I stick with this doctor because I love my children's pediatrician and they're in the same medical group. (I also loved my medical team when I was pregnant).

In 2010 and 2011, minimed was helping me with the pump approval. In 2010 I opted not to get the pump after I was told I was approved, but would have to pay a ridiculous amount of money. In 2011, minimed helped me once again, but this is when my medical group denied me (my request never even made it to Cigna). I tried appealing, with minimeds help, but the minimed rep eventually stopped calling me. I figured...it's a business after all and they were only gonna work so hard for this. That's when I decided to switch insurance companies once again and see if I had better luck.

With all that said, I will definitely call minimed again and see if maybe they can help me figure out this mess. Maybe I'll have better luck this time. However, I'm starting to think that I'm going to have to find a new doctor.

9

Ask your PCP for a referral to and Endo, because they will definitely help you.

10

silver,

#still_young_at_heart is giving you great advice. A1C is just part of the story. Another thing to focus on is hypo unawareness - do you ever have trouble feeling that you are low and find out only by testing? A "Yes" answer adds to your need to have a pump.

Another one to document is your job (as you already said). If your job tasks change during the day or from day to day, this makes you a good candidate for a pump.

You are also taking the right path by getting the pump company involved. They know the ins and outs for each insurance company.

Best of luck, you sound like a perfect pump patient to me.

11

I didn't need a GAD when I was approved for my pump (BC/BS). At that time I was still mis-diagnosed as a T2. I did have to go through hoops with my endo's practice... classes, pump demos, etc. I also have an 80% co-pay for DME until I reach my max.

12

That's completely stupid.. if I could offer help, I would.

I wish you luck getting it resolved, and keep us updated, please!

13

I didn't need a GAD either, and actually have never had one. (I lived in Guatemala at the time of my correct diagnosis to type 1 and they didn't know what GAD was!). I only saw a PCP, who let me manage my own D as he admitted he only had type 2 patients. So I didn't need to jump through any hoops there. I just took the two day training through animas (and declined their phone follow up program)

14

I just wanna say I just got approved for a pump 2 weeks ago with a A1C of 6.9%. so that rule is bologna!!

15

My advice to you, Im sure at this point you are pretty confident what pump you want to go with. Contact that pump's manufacture and let THEM deal with your insurance. That is what these people get paid to do, and they know ALL the ins and outs with the insurance companies. I know it can seem like an easy process, but insurance companies have so many ins and outs that when it comes to medical criteria and getting things pre auth'd your best bet is to contact the pump company and let them deal with your insurance company, they will also get all the appropriate clinical documentation from your doctor's office as well. Sounds to me though from what you describe you really shouldnt have any trouble meeting criteria for getting a pump. Unless they just have some weird off the wall criteria.

Minimed handled my entire pump request. I kinda bypassed my endo, not that he wasn't supportive but it was like well we'll talk about it more at your next apt. I had already pretty much met my deductible for the year and was switching insurance at the first of the year. I contacted minimed on a Monday, and by Wed I was approved and had my pump the beginning of the next week. That is the best way to go, let the pump company deal with the headaches with insurance.

16

This is beyond stupidity. I thought the standards had changed such that no T1 was ever denied coverage for a pump. BUT, this issue sounds like it's with your doctor's office/medical group and not your insurance company. If I'm understanding this correctly, you need to change medical groups/practices - NOW.


While your efforts of self-management have worked thus far, you need a doctor/practice that can truly support you in your diabetes management for the long-run. You never know when you will have a crisis and need that support.


Regarding the A1C Rule - Years ago, insurance companies did have some really arbitrary rules about A1Cs and pump approvals. Some would say they'd only approve you for a pump if you had a "good" A1C, because that meant you were in control and responsible enough to have the privilege of an insulin pump. Others would say they'd only approve you if you had a "bad" A1C because this meant you needed help, thus justifying the more expensive treatment regiment.

The bottom line is that (1) A1Cs are NOT a good tool for assessing diabetes management and (2) a pump is just a tool that may be beneficial for one person and not another, regardless of their A1C or control. There are so many factors that must be taken into consideration - work schedule, life style, insulin sensitivity, whether you're looking to get pregnant, job, etc. In the end (IMO) it's a call that comes down to the patient - what do they feel is best for them.

As far as I know, insurance agencies are relying less and less on A1Cs, c-peptide, and GAD results. Now, they generally just want a certificate of medical necessity, maybe a c-peptide test, and logs of BGs. Some require that you consult with a dietician, and that's fine, because you do need to show that you can carb count. But it's not a big deal.

Medtronic does a great job handling insurance companies, but I don't think your issue is with your insurance company. Rather, it's who you're seeing as a physician. You need to get to an endo and they should get things in order for you to get a pump.

17

I didn’t call BCBS, I talked to the doc who got me to MiniMed and they did the work. I recently asked for a replacement/ upgrade and they still have all the documents on file so, so far, it seems to have gone very smoothly, no call to Blue Cross by me. I think they have barriers built into their phone management that MM knows their way around.

18

I've had United Healthcare for as long as I can remember (through different employers, but same plan administrator). They basically need a letter of necessity from your doctor - and the letter can demonstrate that you're able (smart enough) to use the pump, not necessarily that your health will deteriorate without it.

I'd suggest calling Medtronic and seeing if they have a letter that they could send to your doctor to sign; and if they don't, write one yourself for him to sign. Doctors hate the administrative/insurance aspect of their jobs, but if the work is done for them, they'd be more likely to go ahead and help you out.

19

Yeah, I’m seeing that now. knit illy I thought it was an insurance thing which is why I switched insurance, but that does not seem to b the problem. The attachment to my medical group is really because I love my kids’ pediatrician & I loved my medical team while I was pregnant. I contacted mm already, but I’m wondering now if the 1st thing I need to do is switch to another medical group.

20

*Initially I thought…