This Saturday I got a notice in the mail that the insurance company (NOT Medicare) will not pay anything toward my supplies or insulin pump that I’ve been on since April because they say it’s not a medical necessity.
OF ALL THE LOW DOWN, DIRTY, CRA**Y TRICKS TO PULL!!! I’m so mad I could spit. Watch out now, everyone, here it comes … SPPPPPPPPLLLLLLLLLTTTTTTTT!!!
What am I goiing to do now? After you get used to letting the bolus wizard figure out your doses, not have to worry about carrying around a lot of supplies and keep them cold, what’s left? I give up!!! Evidently I am not worth spending the money on!!! S**t!!
Do you ever go low? If yes, then document a couple of night time lows. Have your doctor write that this could lead to night time visits to the ER. That will cost them a lot more. Then they will pay for the insulin pump.
If you can have a c-peptide test and see how much insulin your body in producing, then you might be able to get classified as type 1, in which case, I think Medicare will cover the insulin pump.
Lois, you’ve got to fight. Call your doctor and have her document anything and everything that will help. Call the insurance company and remind them about your complications. Complications that might have been prevented if you had had a pump. And then keep appealing until they give in just to get you to go away. Grrr, I’m angry for you.
I’m angry enough for all of us put together. I’ve already gone through this once when Medtronic and the DR fought for me. I’ve had a C-peptide and I qualified because what I was making was negligible. I’ve been through this with Medicare and they approved. Been using it since April of last year. I just don’t understand. Am I supposed to turn in my pump?
Lois…I’m going thru some of this with Medicare and trying to get a pump now. If you had the CPeptide and qualified with Medicare, why can’t you have them pay instead of the other insurance that is denying you???or am I not understanding? Like you, I have some other health issues that complicate things (I read your story) and will be happy to share anything I know about Medicare and pumps or if you just want someone to talk to to ease the stress. I certainly understand that. Because of complex health problems, my diabetes is creating a “Life of it’s own” also. We have some of the same problems like the neuropathy.
Karla Sherer
Medicare only pays a paltry sum and I have to pay the rest. The secondary insurance is supposed to pick up the rest. I’m paying almost $430 per month for that insurance and I think it’s a crime to do what they just did. I am going to let my DR and Medtronic handle this if they want. Otherwise, I just may give up. The fight is rapidly going out of me with all the problems piling on top of me lately. I just don’t have the strength to do it anymore on my own.
The first thing to do is appeal. But do so vigorously. Sometimes you can request an apprentice at the appeal committee, I suggest you make that request. If possibile you need to be sure and appear.
Consider an attorney if the appeal does not work well. This is a major money issue, so fight like hell.
Lois…Do you have Medicare A&B? Myself, that is what I have so that’s what I know about. I can’t afford a supplement. I’m 61 so I got Medicare thru my disability. That should not make any difference though. Medicare should pay 80% of the pump and supplies. You or your supplement are to pick up the other 20%. Also, be aware that Medtronic or any of the pump companies I’ve spoken to also have a financial dept. that will be happy to see if you qualify for that 20% to be written off. Because of low income, I qualify for that which is a blessing I’m thankful for. This past year was a bad one for me healthwise. I had a heart cath procedure and two surgeries so I already owe every medical person I know. If I get a pump, they are so pricey there is no way I can cover my 20%. That is why I checked into the financial part with the pump manufacturer. There are usually alternatives and ways around these problems and we will figure out what you need to do beside fight and appeal. That too but I don’t understand the “Paltry sum” you said Medicare was paying. The rule is 80% unless you have some special type of coverage I’m not familiar with. Do you have Part A & B? Maybe it’s because you have a supplemental policy. Is that why Medicare isn’t paying the 80%? Fill me in if you don’t mind so I know what you are dealing with and maybe shut my mouth. I’m angry at Medicare right now on your behalf if they are pulling a fast one on you so I need to understand. I will happily join your fight and help you research or whatever is necessary. Like you, I have extensive health issues and have been thru some of the same feelings, etc. We will find an answer to this what with all these knowledgeable people on this site. BTW, what was your C-Peptide level? I’m curious as I’m getting ready to try again. Mine was a bit too high last time and I’ve since found out that Medicare won’t qualify me unless I make no more insulin than a T1 or at least not much more. Any info on what yours was will be helpful to me.
Karla
I do have Medicare Parts A&B & drugs through my secondary insurance which is different from a supplemental. More cost, for one thing, but they are also to cover at least 80% of what Medicare doesn’t cover. So now, my real concern is the DME (supplies). That is the biggest cost. I haven’t been able to pay anything on the pump and DME yet (since April) to the company they set me up. Medtronic and CCS Medical lied to me and told me they were the only ones who supplied the DME. After a while, I found out that was a lie because, if I would have gone with an “in-network” provider, a portion of it would be covered. Neither Medtronic or CCS are in-network with Anthem Blue Preferred. So, when I fired CCS and went to a local in-network provider, they turned me down. Said Medicare only pays about $50/month for DME for the pump and they won’t take that assignment. There is one in Illinois, EdgePark, but they want the month’s fees up-front before shipment. I don’t have $300-$400 to blow on that.
I don’t know what my c-peptide number was. I can find out, but I never paid attention because I really don’t understand it. I know I barely qualified and, in fact, had to have it done twice before Medicare would give.
What I need to know and haven’t figured out is what Medicare is paying for the pump and how much of a break to ask from Medtronic.
Getting back to Anthem, if they say it’s not medically necessary, they get out of paying for any portion.
Well, I think I’ve about covered it all. If you have any other questions, you could go to my site and leave a message!
I hate insurance companies too! I just went to my rheumatologist today and insurance refused to pay for the appointment so I had to pay! I am not working right now so that is a problem…so I will spend the day on the phone fighting with them to show them I have to go to this specialist as I have autoimmune issues tied to my diabetes, grrrr! Hang in there and do an appeal, it’s a pain in the *ss but you need this pump and they need to pay for it!
I’m so sorry to hear that. Do you need to get referrals to specialists? My insurance doesn’t require them anymore for most cases. The question is: when do they need them? Used to be a lot clearer when they always required them!! Hope you get your money back!!
Yes, I do have to get referrals for specialists which is a pain since I see specialists more than my PCP. I only go to my PCP for my blood pressure meds now. Knock on wood, I don’t get viruses and flus very often so I never need to see him. The specialist needs the active referral in their office by the day of the appointment. My PCP office will only send 3 month referrals and I always lose track of when they expire, hence the disaster that just happened. I have begged the PCP office to do a 1 year referral which most PCPs do. I finally convinced them to do a 1 year for my endo but they won’t do it for the other specialists. I really need to find a new PCP, that’s the bottom line here I think…
Sorry to hear that. You know, I think that insurance companies have WAY TOO D*MN MUCH POWER over our lives and those of the DRs. May they allgo to HE** when they die!
I am not even going to start saying how I feel about what you are going through… I will just say it’s completely wrong.
Here are some thoughts:
(already suggested -make sure to do so) Involve your endo. He can be your ally and they normally have people on their staff that will help you “go to war” with the insurance company until you get approved.
Do you know any local media reporters? Heck… do you know ANY reporters? We could work together to help you create a compelling story so you can reach out to media and see if we get their attention. Obviously it’s not breaking news that insurance companies do this kind of stuff, but I am sure they wouldn’t want the bad press.
If none of this works, do consider involving an attorney. The problem with that is, the insurance companies has deeper pockets than we as patients do… but something else that we could think of, if we can prove there is a trend underneath all this is to explore a class action lawsuit.
