My pump is no longer medically necessary!?!?

So about a week ago, I get this letter from Anthem (my insurance carrier). They tell me that my Omnipod pump is no longer medically necessary and they are not going to pay for a pump order from over a year ago.
Anyway, to save you all my ranting time I’ll cut to the chase. Their records indicate that I have not taken a comprehensive Diabetes education course since 2004. One of their requirements for a pump to be “medically necessary” is that you have taken one of these courses in the past two years. In other words, you have to take a course every two years. (weird that they are requiring you to go to these classes that they know they then have to pay for)
My plan is to take a Diabetes education course (going this Friday) and send them the paperwork asking Anthem to re-review the claim. My worry is that they will not pay for this particular order of pods, about $1700 worth, leaving me with the bill. My question is…has anyone dealt with this particular problem and if so, did your insurance company turn around and pay the claim after they see that you have since taken the required course, ableit after you were out of compliance with their regulations?

Jump through this hoop, no this hoop, no this hoop, now this one…It will never end.

I think that your insurance company personnel should be required to take a diabetes education course so they understand what diabetes is all about. Many years ago my insurance called and the young ditz on the phone asked if I thought I could possibly wean myself off of my insulin because their records showed that I had been taking it for a number of years. Apparently anyone who has taken a prescription medication for a number of years must have an addiction, so she wanted to know if I was willing to try to give it up!

Sigh! I really had hoped that insurance company personnel had progressed beyond that point by now. If nothing else, they should at least ask their folks to Google a medical condition before they make stupid requests like what you are currently dealing with.

Keep us updated on your fight… and good luck!

Hi Russel,I was just wondering how your situation with Anthem is going? I am now going thru the same thing with them…I just received my 2nd denial from Anthem,although I have been using the pods since July 2009…I guess today I will be calling Anthems appeals specialist to see what I need to do next…I hope everything is going well for you! Keep up the fight!!!Patti

Classes? Weaning off insulin??? Oh… MY… GOD!!! Are these people OUT OF THEIR MINDS??? This really scares me… no need to say more. :frowning:

Ugh. Someone from my insurance recently told my endo’s MA (when she was calling for some issues with my insulin RX that they are forcing me to use mail order for) “isn’t there another alternative for this patient” They suck.


I have recently had some success with this. My first step was to send Anthem some paperwork showing that I had just recently taken a class in the hopes that they would give me the “OK”. This did not work. At the bottom of the response form I got from Anthem was a phone number for my endo to call their doctor(s) on the appeals board. She made the call and got everything pushed through. We sent her a Thank You card and a Starbucks Gift Card right away!