Non-Medtronic Insulin Infusion Pump Request under UHC Commercial Plan (PPO)

In UHC website, there are UHC and Medtronic Relationship FAQs:

Will a lot of UnitedHealthcare members have to change which type of insulin pump they use?

…,In fact, we receive fewer than 2,500 requests for non-Medtronic pumps a year (excluding children 18 and younger and Medicare plans.

Question: Does this statement imply that non-Medtronic Pump can be requested with physician prescription for medical reasons? Does someone have experience in dealing with UHC PPO medical plan?

Are all UnitedHealthcare members subject to the preferred relationship with Medtronic?
The preferred relationship with Medtronic only applies to UnitedHealthcare Commercial and UnitedHealthcare Community Plan (Medicaid) members. Children 18 and younger, Medicare Advantage plan members, and UnitedHealthcare Sierra Health and Life Commercial members are not part of the preferred agreement and can continue using a non-Medtronic pump.

Question: This statement does not mention applicability of insurance under AARP Medicare Supplemental Plan F. Does Medicare allow UHC’s discrimination against other Insulin Pump Manufacturers for UHC’s own commercial interest?

You can appeal it, and ultimately you will probably need to go to an external appeal with an Independent Review Organization (IRO) to finally get it over-turned. You will probably not win it on appeal with United, it will be the IRO that might overturn it.

You just have to follow the appeal steps until you get to the external appeal. If you go directly to an IRO, it is not as good, because then you would not have the United denials to use as evidence. So follow all the appeal steps and you have a chance.

Your best (only?) chance of success would be if you are medically unable to use a medtronic pump, and must use a different one. I think there are certain things, such as minimal basal requirements, or tubing. For example, if pump tubing presents an occupational hazard, that would be helpful in your appeal.

Most likely you would not win on appeal because you prefer a different pump.

On what basis could you make a claim that “out of medical necessity” you need a different brand of pump? If you can give a good answer (or more to the point, if your doctor can make the case) to that one, you should be able to get the pump of your choice.

I called Tandem and was given a template for my HR department. I gave it to them, they investigated, and said that since they have an out of network benefit that I could just use that and there was nothing else they could do. Financially I cannot afford it, so I guess I will have to stay with Medtronic even though Dexcom G6 is far superior to the Medtronic alternatives in the 670.

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Or wait.
IMHO it is most likely for UHC to reverse and cover Tandem pumps. The question is “When”.

My guess is a UHC policy change in the 3~9 month timeframe.

Do you have some inside knowledge you can share?

Tandem Diabetes Care specialist explains that the UHC and Medtronic alliance agreement is NOT applicable to the insured seniors at the age of 65 years and older. Insulin Infusion Pump is under DME, which is normally covered under the In-Network. Bryan Healthcare, Tandem’s distributor who handles UHC insured, will contact me later.

Nor is it applicable to Pediatrics.

Combination of public statements on the subject from Tandem in conjunction with what UHC as stated as the primary reason for the decision:

Patient safety was a key consideration. The 2012 ASPIRE study found that pumps
with a Threshold Suspend feature help reduce the frequency and duration of low blood sugar events.

Coupled with the recent August release of the Tandem Basal-IQ update which suspends insulin delivery upon projected (or actual) low BG per Dexcom G6 sensor.

In my lengthy battle with UHC, I was left with the clear indication that the way to win was to find a medical reason why there is a particular pump you needed. If one pump did something that the other pump did not, and it was something that was medically beneficial, it would be a successful appeal.

Personal preference was not honored.

So if Tandem was the only pump that did basal suspends, it would be an easy victory. But since the Medtronic also does basal suspends, I don’t know if there is a medical reason that you could say why you needed the Tandem. The doctor reviewing the appeal could just say that the pumps are interchangeable, they both have CGM and they both do basal suspends.

So that is why I am asking, if UHC has come out and said they would allow people to get Tandem. Or will they stick to their unholy marriage with Medtronic, and say that the pumps are medically the same…

My opinion is tainted by a 7 month battle, so I am clearly not of the belief that UHC will do what is right…

But we will see! :crossed_fingers:
(BTW, that :arrow_up: is crossed fingers, I am not flipping you the bird. :grinning:)

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Good morning Everyone!
i’m just entering into the Tandem/UMR process (HR is on my side and ready to write up whatever paperwork i need) but i was curious if you ever go through @waynec2?
Hoping there’s been SOME positives in the last year,
Thanks in advance <3

UHC and Medtronic agreement is not applicable to those 65 and older because of Medicare non-discriminative rules. However, if you are younger and under UHC commercial plans, it may be different. The best bid is to contact Tandem new patient customer services directly. They may be able to guide you through the paper work.

Due to UHC/Medtronic exclusive agreement, AARP/UHC Medicare subscribers can obtain Tandem pump supplies through 3rd party DME suppliers, but not directly. Good luck.

Thanks Very much! i’m 35 and UHC commercial, but im already in contact w/ Tandem getting me started. Fingers crossed!

If you have not already succeeded in getting a different pump, I have one suggestion: I was allergic to the glucose sensors provided by Medtronic. I cannot detect low blood sugars, and so having the tslim with Basal iQ technology has been preventing my sugars from becoming dangerously low at night. The Medtronic pump can do the same thing, but if you, like I, discover you are allergic to the Medtronic sensors, they may let you switch.

I realized i hadn’t updated! I was able to get my pump through my pharmacy benefits, and it was delivered on 12/20, i can’t wait for my training on 1/3 to get started! im waiting on my last libre CGM to expire to start the dexcom next sunday.