Medicare req'ts

Is anyone around (bsc?) who can tell me why Medicare requires a fasting BG at the same time as a c peptide for a pump? What is the point of the FBG? I had a c peptide of …01 in 2007 and now I need a repeat peptide PLUS the darned fasting. What does that add to the diagnosis? And, it must be less than 225. I can do that, of course, but…sheesh!!

P.S. I also told Liberty Medical that I am not a second class citizen, just because I am on Medicare, and will not accept a refurbished pump for my next 5 year cycle. Am awaiting a response.

C-peptide is a byproduct of insulin production. It is removed from your body quickly, so it is a reasonable measure of how much insulin you are producing. If you are fasting and you have a normal blood sugar, you don’t have any need for insulin (to lower your blood sugar) and hence your body does not attempt to produce insulin. This can lead to a low c-peptide.

So that is the crux of why everyone wants you to have an elevated fasting with your c-peptide tests, you want your body to “demand” insulin production. If your pancreas is trying to produce insulin and nothing comes out, then you really are insulin deficient.

So why do they want less than 225 mg/dl? Probably because having a blood sugar that high could exhaust your pancreas, leading to a transient measure of insulin deficiency. If you recovered a bit, then your pancreas might come back to producing reasonable levels of insulin.

Nell I got the samething last week with ordering my pump. Flustrating isn’t it? I mean like my dr said years ago…“After having d since you were 10 do they really think you’ll get any better??” He said more but right now I can’t remember it all. Thank you bsc I was wondering the samething.

Thanks, bsc. But on the FBG, your theory sounds like a theory that has not been tested. I suspect that if your c-peptide is abnormal, it is not going to return to the normal range, regardless of the BG. It seems to me they would want the fasting to be less than 120 if they want to be sure of the “diagnosis.” Stupid, stupid!

I just found this posting about this subject–very interesting to me!

I know I am just talking to myself here but I am so disgusted with Medicare that I will just keep muttering about it. Today I received a letter from my endo stating that anyone on Medicare (me) or Medicaid must have 3 tests in order to get a pump update and continue to have pump supplies covered. I had a c-peptide in 2007 that showed .01. Obviously, I am a type 1. Or do you suppose that I may have suddenly recovered from it? I am finishing with pump #2 at 5 yrs 8 months and have been diagnosed as a t1d since 1982 (or possibly 81).
Here is the new list that I got:
fasting c-peptide
islet cell cytoplasmic autoantibody test
fasting glucose.

The second test, according to, is usually not ordered as it is “labor-intensive and requires considerable expertise in interpretation.” Instead, the GADA and IA-2A assays are more commonly done. I must call my endo tomorrow to ask who selected the cytoplasmic test–him or Medicare. Of course, these antibody & c-peptide tests are only useful for newly diagnosed diabetics to insure they get started with the correct treatment.
Medicare administrators are CRAZY!!! TOTALLY CRAZY!!! The world is going upside down, especially congress and Medicare.

e.Continuous Subcutaneous Insulin Infusion (CSII) Pumps (Effective for Services Performed On or after December 17, 2004)

Continuous subcutaneous insulin infusion (CSII) and related drugs/supplies are covered as medically reasonable and necessary in the home setting for the treatment of diabetic patients who: (1) either meet the updated fasting C-Peptide testing requirement, or, are beta cell autoantibody positive; and, (2) satisfy the remaining criteria for insulin pump therapy as described below. Patients must meet either Criterion A or B as follows:

Criterion A: The patient has completed a comprehensive diabetes education program, and has been on a program of multiple daily injections of insulin (i.e., at least 3 injections per day), with frequent self-adjustments of insulin doses for at least 6 months prior to initiation of the insulin pump, and has documented frequency of glucose self-testing an average of at least 4 times per day during the 2 months prior to initiation of the insulin pump, and meets one or more of the following criteria while on the multiple daily injection regimen:

■Glycosylated hemoglobin level (HbAlc) > 7.0 percent;

■History of recurring hypoglycemia;

■Wide fluctuations in blood glucose before mealtime;

■Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl; or,

■History of severe glycemic excursions.

Criterion B: The patient with diabetes has been on a pump prior to enrollment in Medicare and has documented frequency of glucose self-testing an average of at least 4 times per day during the month prior to Medicare enrollment.

This was copy and pasted from

It clearly states it can be a C-peptide OR any of the autoantibody tests.

But see a blood glucose of 120 might be more than some people could manage. An insulin pump may be the exact therapy the doctor wants to use the get the fasting blood glucose in line. Making it <120 COULD be the only reason someone would not meet the criteria and although their laws seem crazy I do not think they are out looking to be mean. The reason why most insurance companies do cover pumps is that studies have shown that in the right hands CSII can greatly improve control (know it did mine!) so in the end it is in their best interest to allow the pump if it is indeed a needed therapy.

And remember, hopefully your doctor is on “your side.” He may be ordering both the c-peptide AND the antibody test so that he can submit the test results which give you the best chance of approval.

And while you may feel a bit ruffled about the hoops, remind yourself that the criteria is significantly biased against T2s. You have hurdles that are small compared to a T2. While 20% of type 2s are antibody positive, there is no evidence that being antibody positive says anything about blood sugar control or beta cell loss in T2s. And in a T2, a normal c-peptide may actually be quite insulin deficient as insulin resistance is not factored into the criteria.

Actually, what BSC said is what I heard about the fasting BS. In a T1. it really won’t matter but for a T2, if their BS is high, then the c-peptide will be lower.

I got my pump thru Medicare and my fasting BS was 65 the day I had my c-peptide (just pulled it up to verify the number).

Doris, the fasting part was just added to the rules a couple years ago so your other one might not have been done fasting (or at least wasn’t marked that way). I have a friend that had to get a 2nd one done for her 2nd pump because the first one wasn’t done fasting. Unless they change the rules again, you won’t have to get another one.

I agree with BSC, your doctor probably just wants to make sure you have everything submitted with it so you covered one way or the other. Mine also ordered the kidney stuff, just in case (even though I knew that would not qualify me).

Thanks for all the comments. I just don’t get ordering the test that is hard to interpret. I also know that I already had a c-peptide test in 07 that ‘qualified’ me but now am having to go thru it again and with more tests. It is also wasting Medicare money. all those are reasons I think it is wrong.

But I, like many others, am a victim of a system gone haywire. Oh well…
Oh yes, my dr does support me. He wears a pump himself.

Do you know if that test was done with a fasting BS? If it was, then you should not need to have it again (I know you said you had it done before, but I did not realzie it was only 4 years ago). I wonder if the supply company simply asked for it and someone misunderstood and they thought you needed a new one. The Medicare rules clearly state it is a one time thing - as long as you qualify, you don’t need it again.

I hope not! Hopefully I got it all taken care of on Tuesday but then again who knows anymore with the new rules of Medicade? One thing that took me totally off gauard was that they needed a copy of my bs’s for a month every months (no prob there) but I was used to them having to have a copy of my bs’s for a month a year. Just gotta get used to this new policy.

No Kelly you would think not but I don’t think these ppl at Medicare get the fact that once your a diabetic you are one for LIFE. I get the impression that they tend to think you can get “cured” if you do this and if you do that and always eat “healthy and the right foods no junk foods” As diabetics we all know that once you get it it NEVER goes away. Now we MUST make ppl in insurance (in anyway) understand that!!!

There is no record of a fasting but they usually took one when I went in the dr office. Regardless, we know that logically and scientifically we do not need these tests to know that I have diabetes. The other issues–hypo unaware, etc.–could be checked without the antibody test.

I think we may need a specific Medicare group on this forum!

I think they keep changing the rules to try and prove we aren’t!

Nell, there is a Medicare group here - I don’t think it is real active though. I “think” I joined so I will look for the link for you.