Predetermination that the pump is medically necessary?

I had a chat with my insurance company and they told me “oh yes, your insurance covers the pump provided that there is a predetermination the the pump in medically necessary and being Type 1 does not assure that it is in fact medically necessary.”

what the heck? Is that normal Insurance bs? I’ve never dealt with them before now and it sounds to me that while they claim the pump is covered it’s not really as long as you still have a pulse on MDI. Has anyone else heard this?

Yeah I think it is…they can’t determine for you that it is necessary, and they can’t take your word for it either…so, you have to speak with your Endocronologist to have them inform your insurance agency that you do in fact need the pump. I never try to understand insurance companies…I just try to jump through there hoops so that my wife can have the best medical attention she can get for her diabetes!

Everything that insurance people say is “normal insurance bs.” They are scam artists through and through.

Anyway, I won’t keep going on that because I could write a book on those bastards and what they are/have been doing.

What they are saying to you is that your diabetes needs to be “bad” enough to justify them paying thousands of dollars for it. Remember that in the US, insurance companies make your medical decisions, not doctors (sorry but it’s real hard to resist slamming them).

My endo prepared me for this by switching my insulin and putting me on a schedule that required very frequent shots. He also “guided” me as to how to talk to them about it. If your endo is willing to play along he/she should know what to do to make you look “severe” enough to have it covered.

For anyone else reading this I need to add the disclaimer (in case I didn’t make it obvious earlier) that I am not suggesting that anyone’s diabetes isn’t severe. It’s the insurance companies that set such ridiculous criteria for us to meet before they do WHAT WE ARE F***ING PAYING THEM TO DO!

Can you tell I don’t like insurance companies? :slight_smile:

They should have a published document that states what the pre-req’s are. Make them give you that. My insurance company required logs showing I tested at least 4 times a day and an A1c over 7.0 or 7.5 (don’t remember off the top of my head). If they refuse to give you the documentation you request, complain to your state insurance commissioner

good luck!

Yes, normal insurance BS (START jaded, cynical style here) because they are more interested in controlling TODAY’S costs rather than tomorrow’s even if tomorrows costs are greater (and may include you living a shorter, lower quality life). (/END jaded, cynical style).

What Jonathan hicks said was absolutely true in my case. My doctor knew exactly how to fill out the form(s) and it all happened pretty quickly for me once I decided on the pump.

Fair Winds,

I agree with everyone else. Your doc or CDE can guide you through the hoops. I had the same requirements as Scott elevated A1c and 1 month of logs showing 4 BGs daily, average.

Insurance companies don’t consider pumps a proven money saver. Sad but true. The long term costs vs short term. Let your doc or CDE kow you are interested and it shouldn’t take long. I think it was about a month for me. From the time I mentioned it to my doc til I was pumping.

Yes, I heard the same story and the insurance company ever rejected my first request for a pump, but my doctor appealed and then it was approved.

In order to get improved, my doctor needed to emphasize my nighttime hypoglycemia. Your insurance company (evil or not) does not want you going severely low, especially during the night. That would cost them a lot of money.

The pump lets you have different basal rates and makes that less likely. So this is a good line of argument to focus on. Insurance companies are more interested in the short term than the long run, in my experience. Be sure to log your blood sugars for a month or so, especially any lows.

Agreed with everyone here on everything. I asked about the pump six years ago, and was pumping within the month. Insurance covered half of it at the time (I think they allow more now) and they didn’t give me too much grief about my A1c (which was around 8.0% at the time.)