Omnipod medicare coverage

#1

Hi:
I am anew member to site but not to type1 -more than 50 years.
I have used omnipod for 2 years and only pump I have used. I waited because did not want tubing, etc. Now I find out that medicare will not cover the pod for some unnown reason. Even though my present carrier-BCBS of PA. pays half ot it, it will not do so because of medicare. Has anyone experienced this? results? it is so ridiculous. medicare says not a pump!!

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Medicare, etc
#2

The only thing I can say about Medicare is “You can’t fight City Hall.” I had been an insulin-dependent diabetic since 1957, and my endo Rx’d a pump, but because my C-Peptides didn’t meet some arbitrary standard, Medicare wouldn’t pay for a pump. No other insurance in the country requires a C-peptide test, most settle for an endo’s Rx. Oh well.

I finally got a C-peptide that passed the Medicare standard and am on the pump two months later. And the tubing isn’t all that bad. Its tougher than leather and I’m getting used to it after only one week. One of my friends here in Tu Diabetes, recommended getting a necklace on which to hang the pump when I’ve got my pants down.

Tubing is much better than shooting 12 to 15 times every three days and not being able to measure any closer than half a unit.

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#3

I know it is hard to fight the unseen powers but this case impacts untold numbers of users of omnipod on Medicare. How can a pump not be a pump? In addition, even if my carrier presently reimburses for pod, it says if medicare is involved, it looks to that for coverage even if my carrier BCBS is primary. I will fight like you and hope with good results.

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#4

Hi Richard,
I am sorry about Medicare. I am fighting them too. But if you have Medicare, it is primary, no matter what. The BC/BS is secondary and whatever the Medciare says it will or will not cover the secondary will follow My BC/BS says it will cover but the Medicare has to approve. So far i am still waitinig We will draw blood next week.

#5

Even when the BC/BS was primary for years before, it will stand this way now that you have Medicare.

#6

Medicare considers the Omnipod as disposable, that is why they will not cover it. It makes no sense at all. Just like they have billing codes for the CGMS now, but they still won’t pay for it. My Medtronic Rep said it will be at least a year before Medicare will have contracts to cover the CGMS.

#7

Thanks for reply. How did you find out it claims to be disposable. The pod changes every 2-3 days but still operates ike all pumps. I intend to fight it once I get medicare but need more info.

#8

When I was checking into the pump that is what they told me. I fought them for 2 years to get approval for my pump.

#9

What pump do you have? The medicare regulations clearly cover pumps. What is the issue with medicare that it seems to be hard for coverage?

#10

They consider it disposable becasue you throw the whole thing away. I use MM 722

#11

Hi Richard,
The big hurdle for Medicare is the blood work. They really don;'t take into consideration how badly you need the pump or what your doctor says or what he orders. This to me is just a way to keep from having to spend the money for them. This is what happens when you have people making decisions about your health care who know nothing about the disease process but can use a regulation to approve or disapprove something you need. The biggest thing you need for them to approve your pump is to have your C-peptide down low And your A1C needs to be 7 or higher.

#12

My A1c was 6 when Medicare approved me, my c-peptide was 0.8, I believe they told me c-peptide had to be under 2 but I am not sure on that one. My rep for MM told me the best way to get a c-peptide low was to make sure when you went in for the blood work that you had a fasting blood sugar below 90. The better chance you c-peptide will be low.

#13

These numbers were told to me last week. Apparently there has been some restructuring of requirements for a lot of companies as well as Medicare since the middle of last year somewhere. I would have thought that medical requirements were enough.

#14

Ok, I got my pump April of last year. I am waiting for them to start covering the CGMS now. They have the diagnostic codes for them, but they haven’t started making contracts with any of the companies yet. I am just glad that I no longer have to fight them for the pump.

#15

Has ayone looked at the medicare Regulation that has existed for several yars approving insulin pumps? I see nothing about a requirement for it being non-disposalable. With other pumps, thesites are changed with every few days as well. it seems ridiculous and wrong.

#16

It seems wrong to me as well Richard. I really don’t understand about the Medicare requirements or reasoning I think that medical needs should take priority here and the fact you have been using the OmniPod pump for all this time. There may indeed be legitimate lines of reasoning for these but i feel that too much is left up to individuals to say yes or no here and i disagree about this. I am sorry you will have to fight this and hope you are not made to change your pump to get it covered. Please keep coming back and let me know how you are doing. I start my fight with them this coming week.

#17

I also am a Medicare recipient and cannot understand their refusal to provide coverage for this superb device. I have used the Omnipod for a year, but I have been notified by BCBS (my secondary) that they will no longer provide coverage. I am physically unable to use other models because of limitied manual dexterity – can’t disconnect the tubing from my body to take a shower. At 69 years, I am not real steady on my feet and fear tripping over the tubing when using the toilet. I am writing to all my congressional reps asking for their influence in putting pressure on Medicare to approve the device. If anyone out there can think of agencies that might aid in this fight, maybe we can accomplish approval by 2010. I dread returning to multiple injections when my current supply of pods runs out. Spread the word. Maybe we can get this done…

#18

I’m on a mission. I’ve been contacting all the representatives,Nancy Pelosi,any one that I know has the power to help us. Contact your Congress Person. Tell them in order for us to be able to continue using Omni Pod they must change the code numbers. TheCode numbers are A9274 for the Omni Pod and E0784 for the PDM. What these code numbers do is make these pumps considered disposable. Medicare wont cover them because they are “disposable”

It literally takes an Act of Conress to get these numbers changed. If are elected officials hear from enough of us they will understand that we can be a powerful force,and that they could loose their jobs.

Theycan call Insulet Corporation in Bedford,Ma. The telephone number is 1-800591-3455. Have them speak to the person who is quite knowledgeable about the Codes. I believe his name is Dino.

If we act together we can get the change we need. GOOD LUCK TO ALL OF US!

#19

Hi, new to this site and am searching for latest info on OmniPods and Medicare. I’ve been a pod user for 7 years with excellent to good insurance coverage until I retired 12/31/14. Started Medicare and supplemental insurance this January and had no problem getting insulin and test strips (wasn’t asked to undergo any type of testing).

My previous supply of pods were running low so I asked Medicare how to obtain a continual 90 day supply and they gave me a list of dozens of medical supply companies.
I contacted All American Medical Supplies and told rep I had Medicare as primary and
UHC, Plan N. I was told ‘no problem’ and after taking my insurances she called me and said everything’s fine - my 90 day supply would be shipped that same day. That was June 15.

Mid September I called for a new shipment and was told that Medicare wasn’t approving it because it was “a luxury item”, etc
I then wrote what I thought to be an excellent letter and sent it certified mail.

Had to wait more than 2 months for a decision which was a denial. I literally cried.
I’ve been type 1 since I was 16; am now 67.

I can’t help thinking that something is ‘missing in the mix’ - the fact that C-peptide, etc was not requested. Before I start on the 2nd appeal I wondered if I could sit and talk face to face with a Medicare specialist.
Yes, I now realize that coverage for OmniPods is nil, but I feel as though I can’t possibly go back to multi injections. Also having vertigo and no fine motor movement I think tubing of other pumps would be a challenge but it may be a better choice over shots.
Also, Medicare is not covering cost of insulin in conjunction with pods.
Does anyone know how to get an appointment with Medicare? Terribly upset!

#20

Hi no clue with Medicare but I faced a simular issue with Medicaid but in the end I got them to cover it. U just really want it they will throw u many curve balls. But what did it for me was I told them my current one was broken and need it asap good luck