Aetna POS for me in North Carolina about 7 months ago. I'm also hypo unaware. I'm getting in network coverage - 90/10 via Dexcom and they also allow 90 day supply orders. I went thru pre-authorization, but Dexcom handled everything. My endo completed the paperwork and submitted it to Dexcom who in turn submitted everything to Aetna. Aetna never questioned anything and it only took a few days which tickled me pink!
As I understood from Dexcom at the time of application, Aetna is very strict about having certain diagnosis codes on the statement of necessity from your endo. I don't remember them all, but one I think is code 250.1 which denotes you are truly Type 1 and your endo can only use this if he has a Lab perform a certain test. I think it's called a PEP test, but not sure if that's correct.
First, and probably IMPORTANT, I'd like to emphasize that the ICD-9 code which they're looking for is 250.01, and not250.1. That zero, after the decimal point, is critical!
Now I'll explain the "C-Peptide" test, and why they want to see it.
The "C-Peptide" test measures a by-product, C-Peptide, from insulin production by pancreatic cells. A "true T1" person will have a near-zero level. T2 people, with insulin resistance, usually have levels which are HIGHER than normal. (In T2, your pancreas still works -- in fact, it's working too hard, because your body has "resistance" to insulin's glucose transport properties. In T2, C-Peptide and insulin levels are actually higher than normal.)
The C-Peptide test is a stand-in for measuring insulin itself. Measuring insulin directly is far more difficult and costly. And of course, in Pts. under treatment with insulin, a direct measurement of insulin levels would include all of the insulin being injected or pumped in - so the result wouldn't answer their question anyway.
I could possibly "create a win" for coverage from Aetna for a T2 being treated by insulin, with a history of dangerous Hypos and erratic bGs. But it would be a lot harder than the appeals I have "helped" in the past, which have all been on behalf of T1 PWDs.
That was a lot of words (sorry). The two main points of this post were (1) to correct the T1 diagnostic code in your post, which should have been 250.01 ; and to describe how the C-Peptide test is used to distinguish between T1 and T2, as well as it's more frequent usage of confirming a T2 diagnosis.
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