I was just reading the experiences of Matt in the Insulin Dependant Type 2 group. Matt was using an Omnipod prior to Medicare but was denied a pump by Medicare because his c-peptide was to high.
This concerns me because I'm T2 and I wear a pump. Although I'm still 10 years away from Medicare I would sure hate to lose my pump when I get there.
I might have to cross that bridge down the road but I have immediate concerns for Matt and want to ask here in the main forum if anyone knows of a solution to Matt's problem. I thought maybe the collective wisdom of the group might be able to help. Matt has other health issues and really needs the improved control that he gets with a pump.
Thank you for sharing this. I am only 57 (as of today) and did not expect to be on Medicare so young but I became disabled and therefore no longer able to work. Hence the medicare insurance. Any other input is appreciated.
Can his endo write a letter saying that he needs the pump to maintain good control and this is necessary for overall health? Seems like doctors can write exception letters for most things.
Medicare Part B covers insulin pumps worn outside the body — including the insulin used with the pump — for some people with Medicare Part B who have diabetes and meet certain conditions.
What are those conditions? You must meet either criteria A or B.
Criteria A Criteria A states that you must:
Meet C- peptide or beta cell autoantibody lab test results requirement (blood test results that show that you make little or none of your own body insulin) Complete a comprehensive diabetes education program Have been on a multiple daily injection (MDI) program for six months, using at least three insulin injections a day Provide documentation of blood glucose testing an average of four times per day Meet one of the following: 1. Have an A1C greater than 7 percent, 2. Have a history of recurring hypoglycemia, 3. Experience wide fluctuations in blood glucose levels before meals or dawn phenomenon — an early morning rise in blood glucose or hormone levels Experience severe swings in blood glucose levels
Criteria B Criteria B states that you must have been using an insulin pump prior to enrollment in Medicare, and that you have documentation of testing your blood glucose four times a day during the month prior to Medicare enrollment.
If you have a pump when you switch to Medicare it's relatively easy to keep your pump.
Thanks John, It seems to me that Matt has met Criteria B so I don't understand why he was denied. He was on an Omnipod and should have those records in his pump. The only glitch I can see is if maybe he went off his pump before starting Medicare. Then he would have to meet Criteria A. In that case he could not qualify.
We did go that route. My Dr has sent 45 pages of my history showing a decline in my renal function and an increase in my Bg and A1C levels since off my pump. He also did a peer to peer review on the phone with their Dr. Still denied. Thay basically said to call back when I need dialysis. When I sopke to the nurse in the final review board tonight I said wouldn't it be cheaper to pay for my pump as opposed to dialysis and she said sorry that's the way the system works. UNBLIEVABLE!!!
John G, It is not easy to do, I WAS on a pump prior to my Medicare coverage. I meet all the criteria mention above except the c-peptide. My level is 3.2 and needed to be 1.2. that is the ONLY reason for my denial. They won't budge and consider any of the other criteria I have met, or my declining medical history.
I still don't understand why you don't qualify under Criteria B. It's A or B, right? Sounds like a Medicare Lawyer might be called for. Or at least a letter from your doctor!
John, Here is the memo from Medicare. You have your Criteria letters mixed up.
e. Continuous Subcutaneous Insulin Infusion (CSII) Pumps (Effective for Services Performed On or after December 17, 2004)
Continuous subcutaneous insulin infusion (CSII) and related drugs/supplies are covered as medically reasonable and necessary in the home setting for the treatment of diabetic patients who: (1) either meet the updated fasting C-Peptide testing requirement, or, are beta cell autoantibody positive; and, (2) satisfy the remaining criteria for insulin pump therapy as described below. Patients must meet either Criterion A or B as follows:
Criterion A: The patient has completed a comprehensive diabetes education program, and has been on a program of multiple daily injections of insulin (i.e., at least 3 injections per day), with frequent self-adjustments of insulin doses for at least 6 months prior to initiation of the insulin pump, and has documented frequency of glucose self-testing an average of at least 4 times per day during the 2 months prior to initiation of the insulin pump, and meets one or more of the following criteria while on the multiple daily injection regimen: • Glycosylated hemoglobin level (HbAlc) > 7.0 percent; • History of recurring hypoglycemia; • Wide fluctuations in blood glucose before mealtime; • Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl; or, • History of severe glycemic excursions.
Criterion B: The patient with diabetes has been on a pump prior to enrollment in Medicare and has documented frequency of glucose self-testing an average of at least 4 times per day during the month prior to Medicare enrollment. General CSII Criteria In addition to meeting Criterion A or B above, the following general requirements must be met: The patient with diabetes must be insulinopenic per the updated fasting C-peptide testing requirement, or, as an alternative, must be beta cell autoantibody positive. Updated fasting C-peptide testing requirement: • Insulinopenia is defined as a fasting C-peptide level that is less than or equal to 110% of the lower limit of normal of the laboratory’s measurement method. • 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. • Fasting C-peptide levels will only be considered valid with a concurrently obtained fasting glucose ≤225 mg/dL.
