This Journey through Medicare Part B is not for the fainthearted. I have Medicare, and a good supplement.
CSS has denied me access to the instructions and regulations for documentation required for pump and cgm supplies. Only the Dr. can see this information? Meanwhile the Dr. says he has no idea what CSS wants and keeps re-sending documentation only to have it returned. CSS complains of those ‘darn ever changing medicare rules’ I ask “What are the rules and the instructions exactly pray tell?” “oh, we can’t tell you ( of all people why tell the patient right)…we can only talk to the Dr., have him give us a ring” ummmmm
I had the same trouble in Pennsylvania…now in Texas. Its not the doctors or the pharmacies or the patients. If we all had the same set of documentation rules, regulations and instructions we would could all speak the same language and simplify the entire process.
The law and the documentation rules and regulations regarding all of this should be public information.
Has anyone been able to get a copy or a link to this mysterious knowledge? Does anyone know where to start (no legislators have helped yet)
What about a redacted copy of an effective dr. work order?, what about an itemized list of questions and tests that needs to be submitted by the Dr.
Better yet - Why isn’t there an online form the Dr can complete for his diabetic patients for instant submission…rather than delayed transcriptions and faxes and lab results that get lost in the shuffle.
What exactly are you trying to get covered under Part B? If for instance it is a Dexcom CGM, you can go to the Dexcom website under medicare and it will tell you exactly what medicare requires for a CGM to be covered. Larger hospitals or specialized diabetic clinics have staff that actually coordinate all the paperwork between the manufacturers and doctors but small medical offices are more challenged in processing.
@CJ114 offers an important suggestion: the equipment manufacturers want you as a Medicare patient to have their systems and the typically have useful information.
However, there are requirements and there are “magic phrases”.
For example, if your doctor writes a prescription for “XYZ Continuous Glucose Monitoring System” it WILL be rejected but if it is written for “XYZ Therapeutic Continuous Glucose Monitoring System” you have met one of the CRITICAL requirements for approval.
A therapeutic CGM System is one that the FDA has approved for making insulin dosing decisions with no finger stick corroboration.
The Dexcom G5 (and now G6) was the first therapeutic CGM approved by CMS way back in 2017 but Medtronics and Freestyle also (I think) have therapeutic approval. Any other System is adjunctive or non-therapeutic and not covered by Medicare.
Here is also a link to information provided by diatribe.org that includes what is covered by Medicare and what the requirements are for pump coverage for example:
Note: that article is over 2 years old so it only lists the Dexcom G5 as a Medicare-covetable CGM, but there are others now.
Customer support for the various equipment manufacturers should be your first and best stop for requirements and proper terminology.
This forum is probably next best because a number of folks have been down and ultimately emerged successfully from this path.
It’s trickier, more complex, and more frustrating than it should be, but that is there world we seem to be stuck in …
A really detailed printed document with all of this would be a really great addition …
You might expect that your endo would know all this … but that is frequently NOT the case and you have to be able to walk them through it.
You are definitely right that the Medicare Part B process should not be veiled or mysterious. The rules should be relatively easy to comply with and not overly complex.
I agree that working with the manufacturer is a good place to get information, even if you must work with a downstream supplier. I see an endocrinologist at a major regional medical center and their back-office staff of medical assistants do a great job of sorting out this needless complication. I make sure to compliment them every time I visit the office. I tell them that I understand the frustration of dealing with diabetes supply logistics as I find it especially annoying.
Good luck with sorting this out. It’s definitely worth it as once it’s set up, the supplies arrive and all that payment business happens without any further participation from you!
I don’t see why it is a secret. Depending on what it is you are trying to obtain, Medicare themselves probably tell you what is required. The biggest problem is what Medicare lists as require and what is asked for can be two different things. Usually this is reactionary. Medicare’s auditors like to add additional caveats to the requirements. If a company gets their money taken back often enough then they will start adding those “requirements” in. Typically:
You cannot make an error on the form that CCS sends the doctor. Most companies will not accept errors, you cannot overright it, you cannot cross it off, (you can white it out if you do it perfectly and no one can tell). NONE OF IT. MUST BE PERFECT.
It has to have a “wet signature” (in other words no signature stamps) and must be dated (no date stamps).
If you are new to Medicare, then your doctor must provide a fasting C-Peptide with a fasting glucose drawn at the same time. The fasting glucose must be below 225 and the fasting C-Peptide must be less than or equal to 110 percent of the lower limit of normal. For patients with renal insufficiency and creatinine clearance (actual or calculated from age, gender, weight, and serum creatinine) ≤50 ml/minute, insulinopenia is defined as a fasting C-peptide level that is less than or equal to 200% of the lower limit of normal of the laboratory’s measurement method.
The word “Fasting” MUST be on your test results.
(An alternative test to the C-Peptide is if you are must be beta cell autoantibody positive but, depending on how long you have been diabetic, it may no longer show up as positive.
Chart notes: Typically you must say patient is currently using the insulin pump and has been for the last “x” years. She/he is a type 1 (or type 2) diabetic and has been for the last “x” years. She/he has been testing their blood sugars a minimum of four times a day and has been for at least the last 60 days. (You may have to provide logs for the first time). If your blood sugars are in your pump is it possible that you can print the log off of that for the last sixty days. (I know Medtronic has a glucose log). They may or may not want notation that you have seen the diabetic nurse educator in the past prior to initiating the pump. This all has to be IN the chart note in the discussion that specific to that day’s visit (not in history or on medication list).
It also has to be signed and dated (wet signature, no date stamps). Logs I believe may have to be signed and dated (I would just do it to cover your basis).
There could be more. It would help if I knew what it was you are trying to get. What brand? Do you have a MedAdvantage plan or traditional Medicare?
We personally haven’t had strip issues with Medicare while on the G5. The only issue was when they changed the rules in late 2018 for where we got them while on the G5. We used to get 150 with G5 orders each month, and some additional strips from Walgreens. Then all of a sudden Walgreens couldn’t process the Rx for us and it took forever to find out why. Eventually they told us that Medicare said the strips ALL have to come thru Dexcom.
The solution to that: called our doc for an Rx to be sent to Dexcom, and from then on we got all the strips we wanted instead of the 150 “standard” amount.
It remains to be seen how getting the G6 will mess with our strips but we have plenty of reserve.
I just went through this. Medicare has denied every attempt I’ve made to get test strips under part B now that I’m on the G6. The most frustrating part is that I have coverage for strips under my part D as well, but Medicare is blocking both Walgreens and CVS from processing the order under part D. Walgreens did fill my first order of 300 strips but the pharmacist told me that they’ll get a charge back and will not get paid by Medicare. I have no idea if I’m going to be stuck with a huge bill a couple months from now when all the dust settles.
It ticks me off that Dexcom got FDA approval for no calibration necessary. IT is a crock that G6 users are denied strips. We should get at least 100 per month for when the G6 isn’t attached or working correctly.
I’m testing more with the G6 than I did with the G5. I’ve never had to ration any of my supplies and medications in the past. Now, I’m using 1 strip per day from my recently filled strip order that may or may not end up costing me several hundred dollars.
Thank you for the detail. Very helpful. I have traditional Medicare and a supplement. I have a tandem tslim pump, dexcom6 cgm. Have used Medtronic a in the past . Pumper and cgm for 10 plus years. This is my first non private insurance encounter. Thank you so much for the detail. Now what do you know about insulin and part B
I learned by necessity. The biggest issue was that Walgreens and the doctor’s office wasn’t on the same wavelength. I ended up providing items 1-4 directly to Walgreens myself, once I knew what they wanted. My insulin was then approved in under 30 seconds, after languishing for 2 weeks.
Almost forgot. also have to give them the date of last office visit.
If it is through Traditional Medicare, it should be fairly simple once you get the pharmacy to figure it out. Some pharmacies understand better than others. You may want to ask your doctor if they know what pharmacies are more successful at it. If they have a Tslim (or even a Medtronic rep) they could ask them if they know what pharmacies are better at it. There is usually a little extra paperwork involved, just like with test strips. There may be a form that has to be filled out. When the doctor writes the prescription, on the prescription (he/she can make part of the directions) they need to put the cpt code for your type of diabetes (E10.9 or E10.65 for type 1 and/or E11.9 or Ell.65 for type 2); the code of insulin (Z79.4) and the code for insulin pump use (Z96.41). Depending on the pharmacy, they may not what the codes for the insulin pump and insulin use but, instead, what it written out like, on insulin used with an insulin pump.
(Yes, I know IT is a prescription for insulin, but Medicare is weird with their rules and it is better to be safe than have it come back and bite the pharmacy in the butt. I mean, we are talking about the “insurance” that thought that they may inappropriately paid for test strips because the code on the prescription said insulin use but didn’t specify diabetes. If you want to have a laugh or two read Inappropriate and Questionable Medicare Billing for Diabetes Test Strips done by the Office of the Inspector General in 2013. Some of is legit but some of is kind of humorous…This report is the foundation for all of today’s Medicare test strip woes).
If you have a MedAdvantage plan it is a lot harder because it can be more confusing. Sometimes you have to get the plan to recognize that Medicare states insulin for pumps go through Part B. Sometimes pharmacies are just not set up the to bill Part B for insulin through the MedAdvantage plans (they should be because they can do test strips but sometimes, for reasons I don’t fully understand, it can be different and difficult.) Humana for example can either work or not. You usually have to do a prior authorization (and their prior authorizations can be weird). They say you don’t need a prior authorization and you say I realize that but this needs to be covered under Part B because it is being used with an insulin pump so you need to deny it under Part D and cover it under Part B (sometimes it works best if you are using the insulin that is not preferred with their plan). (At least that is how Humana is locally).
Also, Medicare only covers insulin for the pump if you have met the criteria for having the pump and it is a pump that is covered under Part B. (The c-peptide, 4 blood sugars checks a day, etc). (Technically, not Omnipod though I have heard some manage to get it to go through. Omnipod is covered as a prescription benefit and insulin is only covered under Part B if the insulin pump itself is covered as a medical benefit. Basically, the rule is that medication delivered through durable medical equipment can be covered under Part B).
It’s understandable…Medicare doesn’t classify it with the other pumps because it is disposable and doesn’t fit Medicare’s definition of “durable medical equipment”. Medicare only started allowing it last year or the year before because they changed the wording on prescription coverage about covering “all things relating to the injection of insulin” (or something to that affect) and Omnipod was able to get covered under that rule (through prescription benefit)
I have really started wondering what makes something DME, I.e., what is durable, at least according to Medicare. Dexcom at 10 days and Libre at 14 (and previously at 10). Also my Ostomy supplies, which aren’t even really equipment, and some of which Medicare would cover 20 in a month. Yet, not the 3-day Omnipod.
As for insulin vials, I tried convincing my Walmart pharmacy not to submit it under Part B. I’m starting on Omnipod this week and have been trying to get a Humalog vial for 10 days, but they said they had to try Part B first, and, with doing so, all of the paperwork, dotted I’s and crossed T’s with my Endo. I’ll probably end up meeting the trainer and pulling insulin from a kwikpen (which I’ve seen is possible on YouTube).
The biggest issue was that Walgreens and the doctor’s office wasn’t on the same wavelength. I ended up providing items 1-4 directly to Walgreens myself, once I knew what they wanted. My insulin was then approved in under 30 seconds, after languishing for 2 weeks.