The problem is that it’s not my insurance that has denied me. It’s my medical group. Apparently the process is that the doctor submits a request which is then reviewed by the authorizations dept of the medical group. That’s where I was denied in 2011 & even received a denial letter saying I didn’t meet Cigna’s criteria (even tho my request never even made it to Cigna). This yr my request was “withdrawn” by my medical group pending my CDE’s recommendation, but she said she couldn’t recommend me because she was instructed not to recommend anyone with an A1c below 7%. She said it was some kind of Medicare standard.
Ok, so I spoke to someone from Medtronic & was told that I have to switch to another medical provider so that they can help me. She said, “getting the insurance to approve it should not be too difficult, but you need a medical provider that is willing to sign off on that and right now you don’t have that.”
So there I have it…I need to find a new provider! Uggghhh!
Someone suggested asking for a referral to an endo. That would be the way to go if you like the primary care that you're receiving from the practice. Most new/newish T1s benefit from an endo so tht is a reasonable request that shouldn't annoy anyone.
Maurie
Yes! I just called my insurance & found out my kids & I can be under different medical groups!!! I don’t know why i thought this wasn’t possible! Thank u for the suggestion! Now to finding a new doctor! How do you make sure tho that you’re not going from bad to worse?
I did see an endo once several yrs ago. He wanted to see me back, but my PCP had to make another request to approve the follow up visit. That was denied because I showed that I was doing well. I didn’t question it much back then, but now I see that this should have been my first sign to finding a different provider. I’m happy to have found out that my kids & I can b under different medical groups. I guess it’s my fault for assuming otherwise & not looking into this sooner. But yes, thank u, I’ll make sure to request that an endo be part of my regular medical care wherever I end up.
I agree with others who say this - you need to find an endo. That is how you get your pump. All they do is fill out a form saying it's a medical necessity for you, and bam - you're approved. If you have to have a referral to an endo (my insurance does not require that), then you need to find a new intern/PCP now so you can get a referral.
What a mess.. my GP and CDE are more than willing to sign off for me to get a pump. I went to an endo about 4 weeks ago and tried to get along with his PA, but it became very obvious that we have different personalities.. (she told me I was going to burn out testing the 8 to 10 times a day that I was testing in addition to other issues..) But they are the only endo group in the whole area.. I've just decided to stay with my GP... so you don't really *have* to see an endo, but at least change GP's!
And I'm not saying that my CDE knows everything about diabetes.. but she's been doing this for a long time... I actually e-mailed her to ask about some insurances requiring you to have an A1C less than 7.0 to get a pump, and she said she'd never heard of that before!
Sounds like the practice has just come up with their own rules... and I wonder if it somehow relates to the fact they probably see more T2's than T1's? I dunno.. no matter how we try to make sense out of it, it's obvious something is screwy.
I'm just sorry you've had to wait so long! It seems very unfair to me.
Thank u for asking you CDE about that for me. I’m glad to know that this 7% thing is not a universal standard as they claim. This medical group has several clinics, doctors, specialists, etc under it, but she’s the only CDE & she told me that she only has a handful of Type 1 patients. So maybe this 7% rule does have something to do with seeing more type 2s than 1s. Who knows?! She told me that there is one other guy who has been trying to get a pump due to hypo unawareness (even got in a car accident once with his baby in the car) but was also denied due to being below 7%.
I did call yesterday to ask about some kind of an appeal process and am still waiting for a call back. I’ve started looking for a new doctor but don’t know how to find one who is well versed in type 1 & able to meet my needs. I don’t know any one else with type 1 or anyone on a pump for that matter so asking around wont help.
Anyone here in the Los Angeles area?
I was thinking about something. In 2010, I seen a CDE that said the recommendations were you had to be under 7%. I got my pump in 2011 after giving birth to my son and my A1C was right at 7 if not a little above and that was only because the rise in blood sugars at the end of the pregnancy. I was approved right off no problems at all. Though we had met our deductible and it was 100% covered. At that time it was BCBS now I have cigna and now they tried to fight me on covering my OmniPod supplies but couldn't since I was already on the pump. Not sure why they tried it though. I seem to be stuck at 7% though for my A1C and that's testing 8 to 10 times per day. No idea why.
Do you need a referall from your PCP to go see a specialist? If not then I'd start calling around different endo practices, you REALLY want an endocrinologist in my opinion. Some PCP's may be ok for managing D, but in my personal and professional opinion, most are really behind on the most up to date methods of treating D. Healthcare is becoming more and more specialized, and when you are dealing with something as complex as D, you really want someone who is specialized in the treatment and management. Not a Dr who has just dabbled in it. I would think living in the Los Angles area you'd have several endo's available. If you don't know anyone to ask, start shopping around, make that first appt like an interview. If you don't have good fuzzies or don't see eye to eye with how they wish to manage you, move on to another Dr.
I agree with this. Medicine is so specialized!! Important to ask, even on that first phone call, if the doctor handles Type I diabetes. In the past I've ended up with an Endo who didn't see or manage Type I very much. Mostly, II so that I felt like I was always explaining things to the staff. Nurses, especially because they didn't understand why I'd be checking my BG more than four times a day. LOL :D Anyway, I read Kerri's blog once about that first appointment being like an interview. That really hit it for me because I was tired of going to doctors basically just to get the Rx I needed, but ignoring most of the advice offered.
I was approved for the pump and have had one since October 2011. In 2010 I wasn't able to afford the cost of the co-insurance. They tried fighting me on my supplies but they realized I was already approved so there was no use in fighting with me and my endo about it. I've never seen anyone else other than an endo since diagnosis in Oct 2000.
I saw an endo once in 2010 & did need a referral then from my PCP. The endo wanted to see me back, but my dr said follow up visits weren’t approved. I was under a different insurance then so will see what the conditions r under united health care. So far it seems like everything has to go thru the PCP first. My son has had to see a specialists also & his PCP had to make the referrals. When one of the specialists recommended my son see a dermatologist, his pediatrician said, “I’ll ask, but I don’t think they’ll approve it.” I’m starting to wonder now if this is an insurance thing or a provider thing. The medical group has an authorizations dept which apparently screens the referrals made by the drs. Is this how it works in most practices? The more I write about it the more I see that this medical group is sort of like a kaiser with our actually being kaiser. Forgive me if this is a dumb question, but are there doctors & specialists that operate on their own w/out being affiliated to a medical group? Do these doctors actually submit requests/referrals directly to insurance companies?
You're right. I basically use my PCP to get my prescriptions and other routine bloodwork, etc. He doesn't look at my meter, doesn't ask about lows or highs, nothing. He doesn't even know about carb counting!!! I think I wrote this somewhere in this thread already, but basically, he initially put me on 5 (or 10...don't remember exactly) units of humalin 70/30, twice a day, plus check my BG twice a day only. I know, I know...I shoulda ran away then, but I didn't. He's not a good diabetes doctor by any means, but he listened to me and prescribed what I wanted...humalog, lantus, and 10 test strips per day. That was "good enough" for me I guess, but I'm sure that a doctor well versed in my medical condition would be far more beneficial to me, especially in the future when getting a prescription refill may not be sufficient medical care for me. Oh yeah, and not to mention this pump approval issue I've been having since 2010! Ha!
I'm interviewing candidates now for endo and PCP for me. Anyone interested in the position? :)
So its "the medical group" not the insurance that is making the decisions on whether or not you're allowed to see an endo? What is "the medical group"? All we have to deal with is my husband's insurance that he has through his employer. They've always recommended for an insulin dependent diabetic that I see an endo. My endo had no problems getting a pump put through. My endo said that even well managed diabetics should see a specialist whether it be an endo or internal medicine doctor both of which I was told could do the necessary paperwork for a pump. I know through Cigna that is it can be either one.
From what I understand, there are several doctors and specialists that operate under this medical group. It seems to me that it's kind of like Kaiser where there are several practitioners housed in one place. Patients see their PCP for everything and the PCP makes referrals to specialists as needed. Some of the specialists are at the same clinic as the PCP while other specialists are in other facilities, but still affiliated to each other under the medical group. When a PCP makes a referral to a specialist or to something that is subject to insurance approval (ie: the pump), the "Authorizations Dept" reviews it and determines whether or not the medical insurance will approve the request. That's where I'm stuck...because of my A1C, the medical group is denying my request.
I called the clinic last week to speak to someone from the auth dept and ask if there was an appeal process or something. I also asked about getting a referral to an endo. I was told that I have to speak to my PCP in person about all of this. I have no idea why they're making this so difficult! I went ahead and scheduled an appt anyway for 04/16/12. We'll see what comes out of this. I'll update you all then! :)
Thank you all for your help/support!
One other option - if you know what pump you're going with, talk to the pump company and see if they can recommend a doctor in your area who can see you (given your insurance coverage) and get you started on the pump. The pump companies want to sell you a pump, and if you're a T1, you're pretty much guaranteed coverage if you can find a doctor to write the certificate of medical necessity. In some cases, that certificate of medical necessity is all that's needed.
In the interim, get copies of the following:
- Your latest c-peptide test
- Test results that show you're GAD positive
- All your BG/insulin logs for as far back as you have them
- Certification that you have met with a nutritionist and have received instruction on carb counting.
These items may be requested during the approval process and if you have them ready to go, you'll just help make the process faster.
So, if you've selected Medtronic, call them and explain the situation. They should be able to recommend a practice in your area that takes your insurance and that is more "pump friendly" (i.e., not fixated on arbitrary rules for starting someone on a pump).
Your practice's rules are just ridiculous. It is well-established that, for T1s, pumps are excellent tools to achieve better control and obtain more flexibility. They are simply a more efficient/exact way of delivering insulin and I don't think any T1, regardless of A1C, should be denied coverage for one. In addition, the A1C is just one piece of information and should not be the gold standard for deciding on treatment regimens. Any doctor/CDE who solely relies on an A1C for interpreting the level of control a patient has is not doing their job.
I follow all this stuff closely. I'm a T2 and have been on MDI for 1.5 years. I'm doing well, so there is no big reason for me to move to a pump for better control, but it is something that I am thinking about for the future. But getting insurance approval seems like a huge hurdle and the landscape seems to be changing. I've had some brief talks with my endo about it, she sees no problems. I've talked with pump reps who all assure me that they can get approval. But the whole insurance thing has me worried. I have Aetna and they recently (2/12) made a significant change in their policy (diverging from Medicare). Aetna removed a "pass" for being T1 (particularly the c-peptide requirement). You still get ccoverage if you had a pump before enrolling, but now you only get coverage if you have blood sugar control problems:
a.Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL; or
b.Elevated glycosylated hemoglobin level (HbA1c greater than 7.0%, where upper range of normal is less than 6.0%; for other HbA1c assays, 1% over upper range of normal); or
c.History of recurring hypoglycemia (less than 60 mg/dL); or
d.History of severe glycemic excursions; or
e.Wide fluctuations in blood glucose before mealtime (e.g., pre-prandial blood glucose levels commonly exceed 140 mg/dL);
So now, Aetna makes no consideration of T1 or T2 in its policy for insulin pumps. It has essentially made the restrictive criteria that formerly applied to T2s now apply to everyone. Bottom line, as a T1 with Aetna seeking a new pump, you will now have to demonstrate "poor control." Not necessarily a challenge for most creative endos, but certainly an increased barrier.
I have Aetna student health through May 12th. I cannot wait to get off of it, especially after reading this post and the other you posted (yesterday, I think?).
Now I want to find out United's stance. But I have been told that insurance companies won't share this info unless you are a member, which defeats the whole purpose, to me.
Is there a creative way I can ask them and get results? I asked previously and they only told me that since I wasn't a member yet, they couldn't look up my plan and tell me (which sounds bogus to me- I told them what plan I would have)
I think insurance companies are required to share their policy information, particularly with consumers considering enrollment. So most just make them public, not easy to find, but public. And if the information is out there, I can find it.
United HealthCare follows Medicare and has a c-peptide or antibody requirement. The Medicare policy also requires all patients either have be grandfathered having a pump before enrollment or demonstrate control problems, but Medicare doesn't list strict limits like Aetna.
ps. You can also find more details on United HealthCares stance in their full medical policy.