I appealed the denial of medicare coverage for the pod . This is typical according to Insulet.
However, the reason the appeal was denied according to the intellectuals at CMS9the decision makers) is that the device is not considered DME-duarable medical equipment. The omnipod has a 'code" A 9274 that seems to be slightly dofferent than other insulin delivery system pumps. I have no idea what the material difference can be between the pod and other typical pumps except the infusion devices. The pod and the infusion sets are both discarded after 3 days. The problem is that I am not familiar with other pumps covered because I have only used the pod.
I know medicare is wrong; Omnipod cannot get it corrected; and we lose.
Does anyone have any ideas?
I submitted a 6 page letter from endo regarding medical necessity; documentation from FDA; literature describing the pod as a insulin pump. etc. yet, the response is not DME.
I ASSUME YOU HAVE NOT HEARD ANYTHING ELSE. I HOPE THE INFO I SENT YOU HELPED. II DO NOT UNDERSTAND THE DIFFERENCES TO MAKE ONE SYSTEM A DME AND PODS NOT. MAYBE YOUR EXPERIENCE WITH OTHER PUMP SYSTEMS CAN HELP ME BEFORE I FILE APPEAL. IF IT HELPS, IT APPEARS THAT ALLOWABLE PUMPS HAVE ONE CODE E0784 AND THE POD CODE IS A0274. IT IS VERY HARD TO FIND THESE CODES ON LINE AND THE DIFFERENCES ARE NOT DEFINED.
The ominpod is disposable, hence why its (not DME)… (a pod is not durable/reusable medical equipment so technically they are right) Wish you luck but this has been a problem for a long time… If you want a traditional pump, you will probably be approved… I don’t know anyone who has sucessfully been approved for Omnipods from Medicare… People end up switching to a conventional pump or paying out of pocket. (Wish someone would prove me wrong)… When you get a traditional pump, its considered DME and YOU DONT OWN IT, you “RENT” it… (another brilliant move from Medicare)… I guess they cant find a way to “RENT” you pods… because they want the ability to take the pump back from you…Why they cant just consider the PDM a rental to allow for their revoking is beyond me.
I don’t really have any info to help you out, but wanted to let you know that my pods are covered under DME, so I don’t really understand how Medicare is getting to that conclusion. If Medicare says it’s not DME, I don’t think my insurance company would consider it DME. But, I’m insurance stupid.
Oh, and the infusion sets & reservoirs for other pumps are also covered under DME, and these are disposable as well (like Omnipod) so I don’t understand that sort of rationale, if that’s what they’re using.
Without doubt, this is a very confusing and unfair policy by Medicare. I am covered by Medicare and United Healthcare is my secondary. I am one of the fortunate users because all of my pods and the PDM are fully covered (100% as DME by my particular United Healthcare plan. However, they will not pay Insulet anything until they receive a rejection from Medicare. So every three months, Insulet submits a claim to Medicare, it is rejected, the claim is then sent to United Healthcare along with the Medicare rejection and then it is paid in full to Insulet. I did notice that the agreement between Insulet and United Healthcare lists the PDM as rented equipment and the pods as DME. It is outrageous that some technical crap makes one type of pump eligible for Medicare funding and disallows another.
Hi Richard,
Feel free to contact Murray or I. We’d be glad to provide you with any info that you wish.I was able to get an exception when I was with Keystone65, a Medicare Advantage policy. They covered everything at 100%. Switching to traditional Medicare is what kicked me in the pants, and Keystone (along with almost everyone else) would not state that If I returned to their policy that they would approve it again. They wanted me to switch to them, mail a check, and then they would go through the process to decide if they would cover the Pods. Of course, if they did not, I would never be able to go back to a Supplement due to pre-existing conditions, so I’m trapped.
Its all a matter of cost… Unfortunately thats how Medicare works… A little more on prevention of problems is not worth a pound of cure in their mind… Its getting better (now they are covering more preventative things like dieticians and CDEs supposedly)… If pods costs LESS than a normal pump, I think it would have been taken care of already… The cost of pods eventually is MORE than that of a normal pump and infusion sets… Thats all they care about… They rather pay for complications than prevention or so it feels…
Medicare is ALL about money and nothing more. Their rules for ‘test strips’ (even for those of us on traditional insulin pump) is: 3 test strips per day is all they allow UNLESS you can convince your doctor, Endo or whomever you see for your test strips to write a script for more. You would think that writing a script for more would be easy but it is not. I’ve contacted my Endo office 5 times in the last month begging him to write a script for more than 3 x daily. OK, he writes a script for 6 times a day knowing full well that I am on the pump, I test upon waking in the morning, before and after each meal, plus before bedtime. If my math is correct - that is a minimum of 8 times a day not 6. That doesn’t give you any strips for testing before you get behind the wheel of a motor vehicle, no opportunity to test to see if you are hypo or hyper, and certainly no opportunity to test if you are feeling ill.
Nope, Medicare would rather pay for a hospitalization for DKA or they would rather pay for an amputation than to pay for test strips that may or may not have prevented these conditions in the first place.
I was on the OmniPod from 12-15-08 to 8-20-10. The reason I was forced to go to a traditional pump was that Medicare refused to pay for the OmniPod. And if Medicare refused to pay for it, my secondary insurance, Mutual of Omaha, also refused to pay for them. It is all about money and nothing more.
Richard Meltzer - I’m truly sorry you are having so much frustration with trying to get Medicare coverage. I hope that maybe someday, somehow - Medicare will see fit to cover necessary items for good diabetes management. They also do not pay for any CGMS systems either. So now my Dexcom CGMS is out of pocket expense for me. All I can advise is to stay strong. I’ve been where you’re at, and done what you’re doing. Just finally gave up and went with the traditional pump. Even with that you have problems finding a company that will cover the DME supplies. Just a hint IF you decide to go to a traditional pump and have to choose a DME company…Do not sign up with CCS from Florida. They positive suck when it comes to customer service.
To Mayumi,
I’d lean harder on your doctor. My Dr. wrote me for 10 strips a day and there is no problem getting them as long as you are willing to submit a log of your testing for 30 days to verify the need.
Thanks Iris for the kind words. At this point I am so frustrated, and I don’t mean to hi jack richard’s thread, but dealing with doctors and Medicare is enough to drive anyone’s blood sugar lots higher than it should be.
I have a advanced nurse practioner and a Endocrinologist who both work for the same clinic. One will prescribe medicine that has an adverse effect on my blood pressure. Then I have to try and reach my ANP for clarification. At present I’m taking a diuretic called Bumex which is making my ears ring constantly. I called the ANP to inquire about losing my hearing. I am deaf in one ear and have lost 60% in the other ear. Does she want to change the meds? NO she doesn’t. If I never had to see a doctor again - it would be too soon. Unfortunately I have multiple medical problems that require attention. Sometimes I get very frustrated. Sorry for this rant and my apologies to richard for rambling on about my problems. I have no one else to talk to.
The only difference from a traditional pump is the tubing. You wear the brains. With the pod you hold the brains in your hand. The cost doesn’t seem to be any more than a traditional pump set. The PDM is certainly durable medical equipment. I’ve got 20 years before I am eligible for Medicare. I hope they pull their heads out before then.
Thanks for all replies.
here is some additional ambiguous regulation from my firneds at medicare. Afyer looking at the codes supplied with the denial, I find that medicare has a code or some type of finding that that any pump other than a 'traditional" pump (code E0784) is not medically necessary.! Someone at medicare has made this medical/ legal conclusion. My endo has written in my appeal the omnipod is medically necessary and this seems to be ignored.
I am still filing my appeal and will use another argument that the PDm is DME because it lasts several years.
We all argree this is a money factor only and I am alittle frustratred by fact OMnipod does not appear to be really trying. Maybe I am wrong but it is hard to believe Omnipod cannot solicit JDRF or it Congressional reps to look into it.
Hi Rich,
I hate to be so cynical but I believe it is a case of Omnipod not knowing who to pay off. I’d bet if they were a division of Bayer,etc., these items would be covered.
I agree. I am thinking of adding in my appeal that if Omnipod had the right lobbyist it would be covered and I domintend to ask to see all the information and support for the conclusion made in the decision. I have to be careful not to defame anyone but I will puish it.
BTW, have you decided to swith insurers in medicare ? if so, which carrier and will it cover?
I’ve been unable to find any Medicare supplement that will tell me up fron that they will. Most are stating they will only cover the 20% that Medicare won’t pay, and only if Medicare pays the 80%. Even the Medicare Advantage plan that I previously had and who did cover the PODS will not commit to covering it again if I were to re-enroll with them. They will make a decision after they get my check only. They say I will have to start all over to get an exception, plus, I’d never be able to return to a Medicare Supplement again, and as I am a heavy user of Medical Services, the copays that I paid previously are greater than my POD cost, so that really is not an option.
I would definitely call your rep/senator…I work for a Congressman and we get calls like this (problems with Medicare) ALL THE TIME. The constituent service people in the offices are usually really good at cutting through the red tape…especially in an election year
Hi Jennifer,
I contacted my US Senator and got a form letter back some months later telling me it was not covered. (I needed him for that???) I also visited my Congress person’s office and after a series of letters and phone calls, they told me to submit an appeal. Nothing further they would do, stating that perhaps the congresswoman would consider proposing legislation in congresses next session and would I care to donate to her re-election campaign. So much for the politicians…
