Our 13 yr old daughter (dx’d Feb 2005) wants a pump - chose the OMNIPOD but today we got the dreaded letter from Anthem = denied !!
Their reason : “not medically necessary” and "Omnipod is “investigational” … but she DOES meet their criteria???
Any advice on our appeal process ??
Anyone had a similiar DENIAL letter from their insurance.
I was actually denied at first too. My A1C was 6.5 at the time and they did not feel it was medically necessary either. I am hoping to become pregnant this year and that was my main reason. Seems like there is a special code that your endocrinologist should use and right a letter. My insurance is BCBSNC but after they got the right code and the letter they gave me the go ahead. Good luck! It’s an awful feeling to be denied isn’t it?
Hi Brenda - whew!!! I don’t understand how that can possibly be denied - I don’t have any suggestions except to make a personal call to your insurance provider and speak to a supervisor. My insurance (United Healthcare) has given me complete coverage at zero co-pay for all of my diabetic needs. Omnipod included - although I did have to appeal that coverage because Omnipod’s/Insulet’s billing needs a little more depth in describing the charges - once that was straightened out I have had virtually no problem. From what I understand most providers are willing to accept full coverage because, in the long term, it is considered preventive medicne - covering needs entirely now delays or prevents future issues.
The Omnipod was the only system I even considered because of the freedom their system offers - no tubing, no physical connections and simplicity. And it has been tremendous with controlling my diabetes - I have dropped from a consistently high 9+ A1c to a now consistent 6.7 - once the PDM is set up properly with basil rates, insulin/carb ratio and the other settings it has worked well. I trust it to calculate the proper boluses and it has all worked out.
Best of luck getting your daughter on a pump - it will work wonders for her! Any help I can be please don’t hesitate to ask.
Doug
If your insurance comes through your or your husband’s employer, it might help to work through someone in human resources. One person’s complaint might be viewed differently if the insurance company knows that they might lose the entire company’s business. If your company gets its insurance through a third-party representative, that person might also be able to help. Good luck!
Brenda,
First of all let me say that I always feel bad when I hear these type of stories. Was the denial for the OmniPod or for any pump? I work in the health insurance business and I know that some companies do not yet want to pay for the OmniPod because it is a little more expensive in the long run (anyway on paper that is), they don’t truly understand the OmniPod pump system or that just want people on more traditional pumps. Some companies will only pay for one particular pump from one company (read discounts and kickbacks). I myself was initially denied for the OmniPod from my own company that I work for. They wanted my doctor to write a letter explaining why I had to have this tubeless pump verses a tubed pump. I told my doctor to tell them that I will not be compliant on a traditional pump and that I would probably end up in the hospital again with another $30,000.00 bill for them to pay. I do not actually know what my doctor wrote however I was approved a week later. Did the Insulet people work with you to discuss options?
I know it’s distressing however you MUST find out why they denied the pump, was it because of the OmniPod pump or any pump, and then you must have your doctor write letters and provide clinical documentation. If this does not work then you must go through the appeal process. Again, I work in the business and I know that there are a lot of reasons for denials and some of them are NOT VALID. You are after all dealing with a human being and depending on which one you get and their mood for the day they could approve or deny at their whim. Some of these people think they own the company and it’s their money they are dealing with. Some always deny the first time around like when people apply for disability with social security (SSI), almost always you are denied the first time. They hope you give up. We do not after all have a perfect health care system, far from it. So do not give up, keep your chin up and persevere with this matter at least until all options have been exhausted. If your 13 year old needs a pump and your insurance will not pay for it then contact the MiniMed people. They will finance their MiniMed pump for you. Their pump is a fine product but it does have the tube system, however any pump is better than no pump! I also heard of a group that helps finance pumps for people that cannot afford them, I do not remember the groups name off hand however I will look into it. I am sorry that I could not be more helpful in this matter.
Peter
hi Peter
thanks for taking the time to write to me. I am very thankful for those of you who consider this priority, and share your experiences.
Our insurance has been sent an appeal by my daughter’s endo. Insurance said she did meet the criteria, however the Omnipod was considered “investigational” aswell as their decision was that it was not “medically necessary”.
Our endo. addressed these issues, providing pages of documents re: FDA approval etc. regarding the “investigational” objection.
Our endo. mailed the documents/appeal letter about 10 days ago. Yesterday the insurance called our endo. asking for ADDITIONAL info. on our daughter. (which they already have). All the info. they asked for, was faxed to them, today.
Frustrating part, amongst many, for us, is that our daughter has NEVER considered a traditional pump. The tubeless pump is the only one she would wear. Hold thumbs for us and thanks again for your advice and care.
Hey Brenda
I hope that if they are asking for more information, it is a sign that they are reconsidering. I really understand the frustration and in my case, a fear, about not wanting a traditional pump and not being able to get the Omnipod. The weeks between being initially denied and subsequently approved, were emotional at best. I’m not sure I would have made the switch to a traditional one. I know that sounds silly to some people because the end game is good control but honestly it took a lot of talking to my husband and others (actually on some of these boards) to convince me that a pump is a good thing, “strings and all.” Thankfully, I am able to use the Omnipod and I just pray that you and your family and those out there in the same boat, will be able to navigate the insurance mess and get the system. Sending positive energy your way!
This is in reply to Doug’s note on UnitedHealth Care.
Doug,
I just found out that UHC just dropped Insulet as Out of Network where I now have to pay a huge $ for deductible plus covered only 70% of the pods, when I’m down to the last 2 pods. What did you do to get UHC to cover for your pods.
Thanks.
Brenda, write your insurance company. Remind them that the startup costs of the omnipod are considerably less then the startup costs for any other pump. I would also follow up with your doctor and see if he can apply any pressure to the insurance company. Also right letter after letter to your insurance company. This is awful that a beauracrat has control over your decisions. I mean the FDA approved the omnipod, so why should the insurance company decide that it’s investigational. What this all boils down to is that they don’t have a contract with insulet (the omnipod maker) and they won’t approve it until they do. It’s a insurance company financial reason limiting your choices.
Here’s hoping you have good luck. If your insurance carrier is picked by you, you might try to move to Aetna. They where the first to broker a contract with insulet and have the fastest turn around in getting the ok. Took insulet 4 days to get a yes from my Aetna coverage.
hi Bruce
I appreciate you taking time to support me. Yesterday my husband called our insurance to get an update. The insurance chap asked : “is this a life or death situation” (getting our daughter on a pump). ??? COME ON!!! My husband said to the chap: “No, it’s not a life or death situation, but how about you come and spend a day with us, in our home, and watch as she injects herself … sometimes up to 8 times per day!!.” My hubby also mentioned how she has some scar tissue from all the shots… the insurance chap was apparently “speechless” ! What a question to ask !!!#*#&^
anyway, a very kind lady from Insulet called yesterday to “touch base”. She suggested we call the insurance weekly…which we will certainly do. I like the idea about writing letters too.
Thanks and I hope you will celebrate with us, when I post the good news on here, that she’s been approved. (holding thumbs & praying like crazy)!!
UPDATE 4-28-08
Our appeal was DENIED again. Reason : “Omnipod is investigational”. However, she’s been approved for a “NON Omnipod insulin pump”.
Any suggestions or advice about what to do next ?(our daughter will not consider a traditional pump)
I’m interested to know if any one with Anthem Blue Cross/Blue Shield has been approved for the OMNIPOD?
I am sorry to hear that.my daughter has bc/bs and was also denied.we had our hopes up,did as much fighting as we could.my husband says we fought a good fight but its time to move on to another pump.I know there is nothing wrong with other pumps,but I think we all have a right to pick whichever one we choose.but anyways we are going to look at other pumps again becouse we want to get her on a pump before school next yr.hopefully you get better luck than we did.
I have Tricare and I was denied the Omnipod but not for the reason’s your insurance denied you. I was denied because of my DX. I am from Kansas City, MO moved to Cali almost two years ago and my PCP in Cali had me as Type 2. I went to a Endo’s office and he changed my status to Type 1. I wrote Tricare a nice letter and almost 90 days later I was approved. On 5/13/08 Tuesday, I will become a Omnipod user. I will keep your daughter in my prayers.
I’m also frustrated with UHC and Omnipod coverage. I know it is a business, but it feels like a monopoly in how they can control the choices people make for coverage when my coverage is not a PPO plan, but is UHC Choice. It should be UHC Some Choices! I spent 6 months on appeal, lots of letters and eventually the appeal went directly to my employer (last step in the appeal process). I have a great relationship with this person in our company and he said UHC was just inflexible. I understood there were even threats that it might cause higher rates for the company if it was approved. Finally they set up a different system for me that will cover some costs, but I’m still waiting to learn all the details and that was 2 months ago! I’m curious about UHC Out of Network…when they approved out of network for me they told me that the total costs were mine and nothing would even go toward my deductible. What’s up with that? I’m curious where things stand for you and what you’ve actually gotten them to cover.
YES!!! YES!!! YES!!! today I received the most exciting phone call from Janice @ Omnipod.
After 2mths of struggling with our insurance, Anthem BCBS, has APPROVED the Omnipod for our teen daughter Kim.
After 2 denials and a 2nd Level Appeals Hearing set for June 12 - we got it !!!
The 2nd Level Appeals Hearing is no longer scheduled… they approved it on our 2nd appeal letter.
Many, many prayers went up,… beggin’ and pleading and we are just so very thrilled.
YAYY !!!
Brenda,
Did Insulet (the Omnipod company) contact your insurance company directly? I have Anthem insurance, too, and I got my Omnipod with no hassles at all. Insulet had me fax a form from my doc plus some other info and then they worked directly with Anthem. From what I saw, it looked as if they do that for everyone.
They worked miracles for me. I had my Omnipod exactly one week after I faxed the info to Insulet! I hope that you can cut through this ridiculous red tape – and that Insulet gives you good support.
Janet
Hi Janet, yes Omnipod dealt directly with Anthem. We had two denials and an Appeal Hearing set. Anthem approved a pump “just not the Omnipod” which they stated was “not medically necessary”. Glad you had no hassles… I can’t say the same, but am thrilled with their new decision as of yesterday. How do you like the Omnipod ? any advice for our daughter ? Insulet have been unbelievably supportive, patient and extremely professional. Especially Janice 
Congrats! Your daughter will love it
Brenda, Congrats on the approval! I hope that Kim gets everything she’s hoping for using the OmniPod. So far, so good for me on Day 3.
Janet
Brenda, If your daughter is tech-savvy at all, she’ll have no problems with the OmniPod. Using the PDM is a lot like text-messaging or changing settings on a cell phone. I don’t have any real advice except to encourage her to ask lots of questions. The Insulet folks have been great and so has my nurse practitioner. Today is my third day on the OmniPod and my nurse practitioner said that my BGs are “amazing.” I’m quite proud of myself. lol
I may even look forward to my next A1c! My last one was 9.3, which was part of my motivation to pursue the OmniPod. Just like your daughter, I would NEVER have considered the “other” type of pump.
Good luck to you both! Keep us posted.
Janet