United HealthCare and Omnipod

Diabetes Technology Insulin Pumps
#1

I did the paperwork to start on the Omnipod a few weeks ago. On Friday, I was informed that I was denied "Not medically necessary". So Monday I called UHC for further explanation. I was told that it was disposable and my coverage didn't cover disposable medical equipment.

Has anyone received this kind of nonsense from UHC? Is there anything anyone can suggest to help them get it through their heads that it's NOT disposable? I know the argument originates from Medicare's stance on the Omnipod; I just don't know how to convince UHC that this is wrong especially since so many people are getting coverage for it through UHC.

#2

I think it might help to let the insurance company know that even the tubed pumps have parts which are disposable, such as the infusion sets, cannulas, vials,... I don't know all of the parts as I've only had an OmniPod, but I know there are various tube lengths, insertion types, such as angled, straight in, ... which need to be purchased on an ongoing basis. Our pods are in essence the disposable parts of the tubed pump. Our wireless PDM is in essence the same as their "connected via tubing" PDM. We only change out the pod, not the PDM, same as with all tubed pumps. I hope this helps.

#3

I think there are two levels of confusion about this. First, there is confusion between Durable Medical Equipment (which the FDA has Classified the Omnipod) and "disposable" medical equipment (such as Vgo) or needles/pens. What is confusing about this is that the pods ARE Disposable!!! But because of the connection with the PDA, it is classified as Durable Medical as are the other pumps.
Insurance companies are often charging more out of pocket payments for Durable Medical supplies. In fact this could price me out of the ability to afford my Omnipod in the future . So all of us have to find out what our insurance companies do cover, what the out of pocket costs are , which devices are excluded. I find it surprising that UHC would call a pod "not medically necessary"???? You might also want to contact your Dr. and see how the prescription request was coded. So frustrating!

#4

I would be interested in their response to you and your experience. My coverage is also through UHC. Is it possible that the Omnipod may come under prescription? Omnipod ought to be considered durable medical equipment.

#5

Did your Dr write a letter stating why it’s medically necessary?

#6

I had UHC a at one time. I fought with them for a year. They approved me at first, but never paid…they then told me “sorry, but they made a mistake” I paid out out of pocket.
I changed ins to Fl Blue Medicare advantage plan. I am covered 100%!
Yes, I live in Fl. But, maybe where you live , there is a similar BS/BC.
Dee

#7

Your Doc didn't do the paperwork correctly. Call Omnipod for them to help your Doc's office in getting the paperwork done right. Usually they are very willing to help out on this touchy problem with insurances. They really pulled some fancy footwork on mine with BCBS.

#8

I have Cigna and my child was also denied because they said his "blood sugar was too controlled", his A1C was below 7 and they needed his A1C to be higher for him to be approved. His Endo got involved and the insurance company still refused to bulge. It was 2 week later that i realized that by been denied, they meant they won't pay for the PDM but would pay the 80% copay on the pods. So i purchased the PDM out of pocket ($500) and now only pay my 20% copay on the pods. So you might want to check with them if they are paying for any of it.

#9

I'm switching to UHC due to a new job and called my OmniPod rep prior to make sure it was covered. I also called UHC which said it was covered, but that you may need to order the supplies through a third party as opposed to Omnipod directly. I hope this is able to get worked out for you!

#10

They use Edgepark as their vendor, although I've seen other users here going through other vendors. Right now I have Edgepark, the state Insurance Ombudsman, Better Business Bureau and my doctor's office all trying to explain to these people that the pump is NOT disposable. Hopefully the concept will sink in to someone soon.

#11

I called Omnipod about this and they confirmed that it is classified as Durable Medical by FDA!

#12

Per the quote I got before UHC turned me down it's covered under durable medical equipment which for me means I pay nothing. Still working on this, however I do have a tip for people dealing with UHC for anything - they sit up and take notice when you file a complaint with the Better Business Bureau. This is the second time I've had to do this with them, but it generally brings a direct contact within 24 hours and last time it took less than a week to resolution.

#13

I know for a fact that UHC covers omnipod, as per today.
I think this was an error.
The best is to contact Omnipod and ask them to sort it out with insurance. Or start first with talking to UHC.
Or, what may be the fastest, ask your MD to write a two sentence letter of appeal clarifying the error.
good luck

#14

Wow...that's good to know. Why is it so difficult for us to get what we need?

#15

Unfortunately we are looked at as dollar signs instead of as human beings. I wish I could go back to the HMO I used to have. They would have already had this approved and I would be pumping by now. At this point though, I'm in a waiting game. I did get a call from the lady who responds to their BBB complaints and she's got it fast tracked as an urgent appeal which gives them a maximum of fourteen days instead of the usual thirty.

#16

thanks for the tip! i'll keep it in my back pocket as I transition over to UHC starting November 1...

#17

Not all HMO is great. Just today I got a rejection for pump application from HMO insurance. Reason: A1c must be above 7" Her A1C is 7.0m results of great work, 3 months ago it was over 10. It makes me ..... Let say.... irritated.

#18

I completely agree. I was lucky to have my HMO for 28 years but then I went to work for a company that isn't based in my region. That ended that. Otherwise, I would still be with them. Thank heavens my doctor agreed to continue as my PCP.

#19

Good to know about FL Blue Medicare. I am officially a FL resident although I am a "snowbird" with a "vacation home" in the North. I have been on OmniPod for over six years, and at age 60 was dreading having to find funds for full payment or giving it up in a few years when I go on Medicare. Does FL Blue cover everything 100%?

#20

I swear UHC is the most frustrating insurance company I've ever had to deal with. Apparently they don't get that stress is a major cause of high blood sugar, because they are definitely causing me lots of it.

I just found out that the day they originally denied the omnipod because it was 'disposable', they sent my doctor a letter asking for more information. A letter that he never got for a week and a half. My original denial letter took a week to reach me. Yet my paychecks from Florida manage to get clear across the country in two days.

They've now upheld their denial and the Virginia BOI is scratching their heads trying to figure out what their problem is. Like I said in another post UHC considers us nothing but dollar signs, rather than people. I'll be appealing again, this time to the Virginia Insurance Commission where someone with a brain can figure this out. However, based upon what I found out about that letter to my doctor, it certainly appears that UHC had pre-determined that they were going to fight me on this.