Insurance - Omnipod

So looks like the battle with the insurance company has started. I was told three weeks ago that either a pump or omnipod will be 100% covered. All paperwork was signed off by my doctor and educators. But now since I met my deductible with my hospital stay earlier this year I think they are trying to jimmy their way out of having to pay for it. Their first reason was I didn't test my blood sugar enough everyday. I suppose 4-5 or even 6 times a day isn't enough for them. It is though - they just made that up. Second reason was I wasn't compliant with my diabetes education. I found this odd because it was my diabetic educators who helped me fill out the paperwork and suggested I request either a pump or the omnipod. My Endo also signed off on all the paperwork.

All in all - there is a reason why they don't record their phone calls. It was as if they just try to make such incomplete sense that maybe, me the patient, would just give up on it. Now they said I have to write an appeal letter and won't be able to apply for another 6 months - and guess what happens at the beginning of every year? deductible reset. I bet if I waited to ask them Jan 1st this would have never been a problem.

Both my educators are calling the insurance company today and putting them on speaker phone to discuss this with them. They are not happy - nor is my Endo. Has anyone else had similar issues? I really want to stop using the insulin pens and having to take 4-5 shots a day. I have worn test pods and really really love them.

I fought our insurance company for 6 months to get a Dexcom for my son. Their first reason was that he is too young (he’s 10) and that there was no medical benefit for someone “so young.” Then when I tried appealing, they just never seemed to receive anything I sent them - even signed certified mail. But we won - so there is hope! Well, except for the fact that it’s been another six months and they haven’t actually PAID Dexcom anything because of “incorrect paperwork,” but anyway - if you have good people on your side you should be able to do it. Good luck!!

I feel for you, man! I went through many similar events back in 2005 when I was switching to the ;pump after a massive brain nhemmhorage, and the insurance company found every excuse they could find! I agree with Natasha, stay close to your friends (endo, Nurse educators, etc.) as they can be indespensible. Also give Insulet a call and tell them what is going on, and they will help! I have endured many battles with my insurance company, myself, and I am on a crusade against them! Interesting your company is saying you dont test enough, as mine told me i test too much and they wont cover all the strips that I use! I eventuall won that one as well, I just keep plugging at them until I become a nuisance, read my entire story (nothing for sale here, I promise) at Lets get em!

Sorry to hear this. If they still deny coverage, you could formalize the process in writing and get them to state their denial in writing with the date and when you appeal, you may get it covered as of that date (with no deductible reset). It sounds like you have a great team going to bat for you, so it’s gonna happen one way or the other.

Hi Nick… unfortunately I’m also having a great deal of problems with Horizon Blue Cross Blue Shield. I’ve been on the OmniPod pump since August of 2009 at which time I was told by insurance co AND OmniPod that I’d be covered 100%. 2 months ago I received a letter from the ins. co. that they’re only paying 1/2. I did everything… called Insulet, sent a letter of appeal to insurance co. but I was still denied full coverage. I ended up calling a lawyer and they wouldn’t even touch it because they knew it was a no-win. So now I pay $138 plus change a month but I don’t know how much longer I can do that so I may have to go back on the pen. I really hope everything works out ok for you.

Well, Sister Sarah, here is your death panel. It’s is year end and the insurance companies need to report stellar profits. Utilization hurts their bottom line. Luckily with the new health insurance reform, they can’t just drop you. I wish you the best of luck. Someone at an insurance company made decisions about your health care. Their motive is for profit – that’s what for-profit companies do. Insuring the sick is a no win situation for them. This kind of thing is infuriating. I wish you all the best in this coverage dispute. It’s amazing how they can lie as easily as breathing.

Thanks everyone for the suggestions. I will find out what the game plan is here in the next 30 minutes or so. My educators war call should be done by then. My endo thinks they want documentation - written down on paper of all the times i have tested my blood sugar, which to me and to him seems to be overkill. Why not just download my meter? I also told me educator about getting a dated letter of denial and repeal before the end of the year. They too have seen other diabetic patients who are not nearly as a model patient get approved for these devices.

SF Pete is right. Its all about being the end of the year and their bottom line.

Interesting…;. now I got an issue going on! I have just called my local CVS to refill my order of strips, and “no go”…“Your insurance wont cover you until November 23rd” " They say you should be testing 4 o 5 times a day…and you are testing 8" So…the insurance geniuses are correct, right? “No, sir we didnt say that, but they wont cover you” So, once again, we are &^%$#’'d! Thats OK…I’ll just shell out the $70 for my strips! jAnd this is the STUPID insurance company that bugs me about 10 times a month to join their “Diabetes Education Club” where one of their nurse “experts” will guide me daily and tell me how to drop to testing 3 times a day, and still remain healthy!

It sounds like its a profit issue for them. I hadn’t had any diabetes education until I went for an introduction to pumping and then took the three classes my center offers. When I was first (mis) diagnosed as type 2, the insurance carrier I had then only allowed one hour of education. I skipped it to keep it available if I ever got in a bind and needed education desperately. So until I went for the intro to pumping class I had had no education.

I was fortunate that my approvals were routine. In fact, my Dexcom CGM approval came in two hours. My CDE said she had never seen one approved so fast. I guess my hypoglycemic events and two visits to the ER didn’t go unnoticed!

My doctor wrote the strips prescription to test 10 times a day so I have no problems with strips. I guess he knew what he was doing. I even questioned the 10x’s in the beginning and he just told me to test as many times as I needed.