Type 2, Tandem T:Slim X2 & Medicare

Just got off the phone with the regional rep for Tandem. Yesterday I spent an hour with a diabetes educator in person and on the phone with a Tandem rep in San Diego. It was looking like a go yesterday. Then the regional rep dropped the hammer, evidently Medicare or the Aetna Advantage plan won’t approve without a current C-Peptide of <1. The last C-Peptide I had was about 8 years ago and was in the low end of normal.

We shall see. I was really wanting the pump to decrease insulin cost as it would be under Durable Medical Equipment, Part B.

I am doing fine on pens with an HbA1c of 5.3%. AGP for 30 days Avg Gluc 107, in range 99.5%, .5% low, 14.8% coefficient of variation and SD of 16.

Update - I found that C-Peptide in my computer from Nov 6, 2017, it was .8ng/dl. Passed that on the the rep and she said that’s good enough. .8 was the lowest to be considered normal

When I got my Tandem pump in 2020, my insurance required a fasting c-peptide and a blood glucose test at same draw. Not a Medicare plan, but my plan was following MC rules.

If your bg is low, then a low c-peptide is normal.
If your bg is high, and c-peptide is low, its an indication that your pancreas is not making any, or enough insulin.

So you may want to find specific details from your MC plan to determine if both bg and c-peptide are required, fasting or non-fasting.

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It’s weird. I’ve never been asked for a c peptide test.

My doctor has always just put the order in and I get it a while later.

Maybe if you have a diagnosis of type 1, they don’t ask for it.

I had one 30 years ago and not since.

Medicare has been doing this for awhile…

That explains it then I’m not on Medicare

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Keep on breathing, Timothy, and you too can enjoy the wonder out maze of Medicare. :rofl:

I never figured I would live to see Medicare, either I would die or it would go bankrupt.

Well I’m 9 years out now. Still time. I want that Medicare where you just go to the doctor and get what you need.

Remember that…neither do I. Why is it so complicated.?

Here is details on MC requirement. Not sure if Advantage plans may be different.

https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&NCAId=109

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Ah, @MM1 I don’t think I qualify if these are the current Medicare requirements for pump coverage.
1. Glycosylated hemoglobin level (HbAlc) > 7.0 percent - NO
2. History of recurring hypoglycemia - Seldom
3. Wide fluctuations in blood glucose before mealtime - NO
4. Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl - Never let that happen
5. History of severe glycemic excursions - NO, if I understand correctly.

Criterion b

  1. 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.

Did you catch that eligibility is satisfied by meeting either criterion a or criterion b? Are you already on Medicare, Luis?

Rereading the thread, it appears that you’re already on a Medicare Advantage plan.

That’s great you can attain this with MDI. With pens and newer insulins, and cgm, it has been easier to achieve. Many on pump don’t achieve that.

The link was to primarily describe the C-Peptide criteria, but the document is from 2004.

Here is a link to 2020 document regarding pump CSII MC coverage. (Download pdf).
https://www.cms.gov/outreach-and-educationmedicare-learning-network-mlnmlnproductsmln-publications/icn909470

You should check directly with your Advantage plan to determine their specific criteria. But they may ask for evidence to show it is medically necessary, not just a preference.

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