Pumps and Approval

Here’s the deal - my doc agreed that I could benefit from a pump. She completed the certificate of medical necessity and sent it off to Liberty, the supplier my insurance (Federal BCBS) works with. The certificate of medical necessity lists me as T1, notes that I take more than 3 injections per day, and indicates that test 6-8 times per day. To my knowledge, no other paperwork was sent over (i.e., no bloodwork or anything). However, she had some question as to whether I would be covered because of how picky the insurance companies can be with pump approval.

So, Liberty is basically saying that it’s pretty definite that I will be approved based on their experience, although of course they cannot say that for certain. However, they cannot file a claim for the pump until they mail the pump and all associated supplies out to me. BCBS will not “pre-authorize” and they won’t pay a claim until the pump is delivered to me.

I signed a statement from Liberty saying that I am going to keep the pump in its box (sealed) until we know for certain that Federal BCBS is going to pay this claim. If I break the seal and the insurance doesn’t cover it, I am liable for the whole cost of the pump.

Has anyone been through this? If so, what was your experience? Did BCBS ask for additional information? Or did they pay the claim with just the certificate of medical necessity? How long did paying the claim take?

I was told to call back each week to see if the claim had been paid, and Liberty is going to see if they can expedite the claim so that I can get started on training. In the meantime, I have to hold on to an $8000 piece of medical equipment and be liable for it, which makes me really nervous. Why do they make you go through all of this?!?!?! Wouldn’t it be easier to just approve it first and then mail it out??!

And, of course, my BSLs have been horrible today. Haven’t had one reading under 160, been taking insulin and have hardly eaten anything. Grumble, grumble…probably all the stress from being on the darn phone for 2 hours with Liberty and insurance.

It took 30 days for a different BCBS company to approve my pump but I am not sure whether that was their procedure (stuff gets faxed, time to review, approve and pay claim) or if it just happened to coincide with the state regulatory obligation (…to respond in 30 days to written requests in Illinois?) since I didn’t get a letter from them, I got a call from the doctor to schedule the appointment for the appointment to “install” the pump, sort of a class in using it, with the doctor (probably a long appointment, for which the insurer got billed and the sales nurse? My regimen, instead of being one shot in the AM and one in the PM, which was the standard R/N shot regimen, involved lots of shots and dozens of little notes and arrows scribbled in the margins of my messy log. They estimated the TDD but seemed to do ok, since I only had to turn the pump down a little bit form their guesstimated numbers, which I attributed more to being more active than the typical 230 lb 40 year old?

I don’t think you are liable for it, as the pump is still under warranty so if something happens to it, they just send another one? They are pretty sturdy as mine was fallen on several times in martial arts classes and has endured several bike wipeouts without so much as blinking and a couple falls to the floor to boot.

Thanks, that’s helpful. They are telling me it should be faster than 30 days, and 30 days is the maximum amount of time they have to approve a claim. However, Liberty Medical cannot bill my insurance company until they actually ship the darn thing, but when I receive it, it will not have been officially paid for. Basically, if something happens to the pump while in my house (i.e., I get robbed) or I break the seal on the box, I become liable for the full price of the pump. I guess I’m just annoyed that the pump has to physically be shipped to me BEFORE I can find out that it is covered by my insurance. Just seems like a HUGE waste of time. If the don’t approve it for some reason, I have to ship the darn thing back.

From what I was told, I will likely meet with a pump specialist at my doc’s office or a Medtronic rep. I will hopefully find that out soon.

Other than figuring out if my insurance will cover the costs of the pump, everything else about this process has been really smooth…Medtronic and Liberty have both been great and have worked REALLY fast to push things through, as has my doctor’s office. So, at this point, I’m hoping, hoping, hoping that insurance comes through and I don’t have to go through some really annoying appeals process.

Please keep some fingers and toes crossed for me out there!!

I got my Minimed 522 through Liberty in 2007 and had to follow the same process. I kept the pump in the sealed box until BCBS approved payment. That was four years ago, and I’ve forgotten the associated frustrations. But it was approved, and I am very thankful for my pump. Hang in there!

Hmm, I didn’t have the sense of being “responsible” for the pump at all but that’s totally not the sort of detail I would have paid attention to either.

Yep, they (Liberty) made me sign a statement saying that I was responsible for the pump and that I would not break the seal on the box until my insurance company paid the claim. The statement also noted that if the seal was broken or something happened to the pump, I was responsible for the entire cost of the pump.

Strange. No, I didn’t have that experience either, but pump approvals seem to be a very varied process. For me, the Animas rep called my insurance company and a few days later called me back and said I was approved. Then the Then the Clinical Manager contacted my doctor (who admits I’m his only type 1 patient and basically just lets me manage my D), and the doctor’s office contacted me and requested me to get a current A1C done. I did that and then the Animas rep took the form to the doctor’s office filled out with the A1C (which was 6.4) and a recommended starting basal dose and had the doctor sign it. Done. Pump mailed. When I received it I contacted Animas and they put me in contact with the Trainer in my area who came to my house for two sessions. (to train and start me on saline, and then 5 days later on insulin). I declined the follow-up service. I guess I was at the easy end of the continuum of what people go through to get their pumps.

Financial responsibility in my case was a non-issue as my insurance covered 80% and then I had the remaining 20% waived due to income level for which I had to fax in verification to Animas.

I have BCBS/Anthem, just normal insurance through work. MM obtained approval from Anthem before shipping the pump so apparently a third party supplier works differently than most people’s insurance. Not sure. I called MM a couple of times when I saw that Anthem was still listing my payment to MM as in process, but that was for like a month. Finally I got the company’s insurance broker involved and a week later it was paid. Hope things work out for you.

Thanks, yeah, apparently, BCBS Fed uses Liberty as the supplier. Everyone keeps telling me that it will “most likely” be approved, but no one can make any guarantees. I will have sit there looking at my new pump for 2-4 weeks before I will know if I can use it. If BCBS doesn’t approve my claim, I will have to either ship it back and/or begin the appeals process. I have been told to call BCBS each day and see where my claim is in the process and if there’s anything they can do to speed it up. In addition to just wanting to get started, I don’t like the idea of having a really expensive piece of equipment sitting in my house that my insurance company may not cover…I just find it so weird that there is no way for Liberty to know ahead of time whether the claim will get paid, and that there’s no way for the insurance company to let me know ahead of the pump being shipped out whether they are going to pay the claim. Seems so…odd.

It definitely seems odd. I’m also surprised Animas would go ahead and ship it prior to approval. Odd, odd, odd. LOL. Though it does seem like there is a wide variability in the pump starting process.

I would call every day and tell them to hurry the hell up!! That seems very odd that they would tell you to call them every day. I work for an insurance company (p&c) and, while I certainly don’t mind interest in a claim, I usually am working to resolve questions so people don’t have to call back.

Yeah, the Liberty people said that calling each day will help “move things along.” Apparently, if there is a medical need, they can “fast track” the claim at BCBS and send me something in writing ahead of when the monthly EOB statements go out. I don’t know…honestly, I’ve very rarely had to deal with my insurance in the past, so this is all sort of new to me. I’ve always been healthy and it’s the first time I’ve had to get involved with something like this, so don’t know what’s typical.

I’m not even trying to think about it from “our” side of the “barbed wire”, i’m thinking about it from their side? “call every day because we suck” seems like a very strange paradigm to tell someone to call every day. I read medical records @ work all day and, while perhaps I’m biased, the whole pump approval process seemed like a big “rubber stamp” in my case.

It took us about 5 months and alot of pushing for my daughter to get her pump. We began the process in Nov. and got approved in March. And we’ve taken all the classes needed but we are still waiting till June. Her doc wants to wait till school is over so she can concentrate on the pump and it’s functions all summer. So that when she goes back to school in August she has it on. But let me tell you it’s frustrating because it’s sitting in my closet un opened and untouched. Now we count every thing that she eats and write it down. We calculate carbs and use the ratio that we were given. More shots that way but it will pay off at the end. I feel your pain and frustration.

This is what I’m afraid of. We want to try and get pregnant this fall and if the approval ends up taking 5 months, I’m not sure what we’re going to do. Everyone keeps telling me the pump is the way to go with pregnancy, because it will allow for a lot of small, fine adjustments. But I want to make sure I have the time to get through the learning curve before pregnancy. I am an adept carb counter and keep meticulous records of all my carb intake, insulin dosages, and exercise. Thus far, the insurance company has not asked to see these things, but I have them ready if they do.

I WAS APPROVED!!! Pump is arriving today and I’m waiting to schedule training. Thanks all for your advice/guidance. Can’t believe this all happened so fast!

Congratulations! What kind of pump do you have?

I got the Minimed Revel. My endo and I agreed that given my lifestyle and needs in the coming year, it was the best option. I know their CGM isn’t the best, but I’ve heard they are going to make improvements with a new sensor. Someone from Medtronic is going to reach out to me in the next day or so to get things all set up. I’m nervous and excited. I’ve had a lot of BSL fluctuations these past few days and I’m hoping the pump (once I perfect things) will take some of that away. I seem to always been “between” insulin doses, and my endo felt the pump could help with that.

Thanks for the info. The warranty on my Minimed 522 is up, so I’m looking at options for a new pump. I’ve been happy with the 522, except the basal increments (.05) were too high. The Revel has fixed that. I’m also considering the Animas Ping, although I would probably NOT use their meter/controller: I do not like One Touch, mostly because their test strips require such a large sample. I use the Contour USB meter with my Minimed pump quite effectively. Looks like I could do the same with the Animas. I do use Calorie King paperback book frequently for carb counting, so that built-in functionality is interesting. Unfortunately, it appears to be in the meter and not the pump itself.

Lots of trade-offs …

I know you’ll love pumping, once you get over the initial education. I highly recommend the John Walsh book Pumping Insulin. It’s a classic in the pumpers’ world for good reason. Get a copy!

I am going to pick up a copy of that book tonight. I read Think Like a Pancreas and it has literally become my bible.

I was really torn between the Ping and the Revel. Honestly, I liked the design of the revel a bit better (it seemed easier to stash in my clothes) and their customer service has REALLY impressed me. My endo was leaning a little more towards the revel but said she would support either the Ping or the Revel. She said a lot of her female patients liked the remote feature on the ping, but then I read about all of the problems with the remote and decided against it.

Anyway, I’m looking forward to it all. It’s a challenge, definitely, but one I think that will help me in the long run.