Insulin pump denial
Hello. I'm new to this site...came here because I need some advice/direction. I was diagnosed with Type 1 diabetes 4 years ago. I did a ton of research and decided pretty early on that I wanted to go on a pump. I remember reading (back then) that part of the requirements to get a pump was to be able to demonstrate competence and discipline in managing your diabetes with MDI. I've done that this whole time. My most recent A1c was 6.3. I've actually managed to keep my A1c between 5.7 and 6.3 for the last 4 years! However, that comes with a lot of work (and honestly with a lot of lows too). I check all the time though, so I've never passed out or anything. Excercise, even just walking, will usually send me down. I have a lot of swings too sometimes from high to low. (I'm on lantus...tried levemir a short time and that worked better for me, but my insurance doesn't cover it!) My job complicates things too often because I have a crazy job with a crazy work schedule at times. Planning for anything, even meals, is pretty tough due to my job. And once you add my 1 and 4 year old kids to the mix...well...lets just say I'm convinced that the pump would make diabetes management so much easier for me.
Anyway...the trouble I'm having is that I have not been able to get approved for an insulin pump. In 2010, I was told that I was approved (was with Blueshield then), but was responsible for 50% of the cost. I couldn't afford that so in 2011 I switched to Cigna. That year I tried again and was denied by my medical group, not Cigna, because they said I didn't meet "Cigna's criteria" of having an A1c above 7%. So...2012 I switched to United Health Care. I spoke to several people from United Health Care and reviewed their criteria on line and there was nothing about needing an A1c above 7%. This time, my request was "withdrawn" by my medical group and I was told to first meet with the CDE so that she could determine if I should be recommended or not. I had met with her multiple times in the past and she always pushed for the pump for me. I was sure she would make the recommendation. When I met with her last week though, she said that a week earlier she had a meeting where she was instructed not to recommend anyone with an A1c below 7% for a pump. So I'm at a standstill again! What's odd though is that in 2010 I was approved even though my A1c was below 7%. I mentioned this to my CDE and she said that "maybe the rules changed."
My question is, is this A1c rule my medical group is insisting on a standard for everyone? Has anyone on here with an A1c below 7% been approved for a pump? Any ideas as to what I can do? Would changing to a different medical group make a difference? Any ideas/help with this matter would be GREATLY appreciated! (btw...thanks for reading my long long post!) :)
Replies to This Discussion
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Permalink Reply by MyBustedPancreas on -
Interestingly, one of the reasons my endo pushed me to get a pump was because my work schedule is growing more and more hectic (what with travel and working late, etc). It was, for me, one of the main "qualifiers," because sticking to a rigid schedule (as is generally required with MDI) wasn't working for me. That, combined with my insulin sensitivity, was why my endo pushed me to go back on the pump.
Yes, timing is critical because you will need time to do the training, meet with the pump trainer, and just learn how to use it. That said, there are some great videos on YouTube that show people operating both Medtronic and Animas pumps. That's mostly how I learned. But neither of the pumps are that complicated (my iPhone is WAY more sophisticated than my pump). The hardest part is figuring out your basal rates.
I agonized over which one to get - the Minimed Revel or the Animas Ping. For me, the Revel won out for a variety of reasons - Medtronic's long history dealing with pumps, reliability of the pump itself, size, ability to have smaller reservoirs (my TDD is under 30 units/day), fewer button pushes, great customer service. The only thing I like better about the Ping is that screen. So easy to read! I think either are fine choices, though.
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Permalink Reply by Cherise on -
There is also the tubeless pump, The OmniPod. Though I guess people for some reason don't like it. I have it and love it.
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Permalink Reply by Elizabeth on -
An a1c does not measure consistency in blood glucose control. All those lows could be artificially contributing to a low a1c, yet you don't have good control. Do you keep a log of BGs? Can you show definitively that your BG is unstable (that is, going from low to high on a regular basis, rather than staying steadily between 70 and 150)?
What you might do is keep a log of your BG readings (and, make sure you're testing at least six or seven times daily). When you have a month's worth of readings, calculate averages for morning, midday, evening, and nighttime. THEN (this is key) figure out the range of BGs for each time period. If you can show that your BG fluctuates widely, not only from one time period to another, but also from one day to the next in a similar time frame, you can make the case that the a1c is masking pretty serious lack of BG control.
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Permalink Reply by Fighting for Stephany on -
I know that process is really stressful and the insurances love to give run arounds and deny approvals for pumps. It took us several years for my daughter to get hers, I pushed and huffed and puffed with her endo for it, and got it approved. She has been on it for a year now and we still struggle with the insurance mind you shehas medicaid and it's a worse process cause their criteria is rediculous. A pump is a beneficila tool to all diabetics wether you are type 1 or type 2, if you are insulin dependant than a pump should be approved as long as you receive the right guidence and training. But don't give up, push for it and advocate for your self because it's your health.
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Permalink Reply by Cherise on
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That's why I never tried getting one when I was on Medicaid for awhile. This was back in 2009 when I wasn't married to my husband. There were so many hoops to go through that I decided it wasn't worth the pain because every time the educator would tell me we had everything we needed for the insurance it would be denied and another thing added to the list. I just finally got sick of it. I'm off Medicaid now and married to my husband and got my pump last year. Didn't have to go through any of the hoops that I had to go through for it when I was on Medicaid. PS. This is Disabled Medicaid I had and not the Medicaid for children. I wasn't denied at all with regular insurance like I was with state insurance. I guess it just the state not wanting to pay for things.
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Permalink Reply by acidrock23 on -
One recent thing I ran into is that it was eerie how quickly I could get a new one when my warranty expired. I called them and about 10 days later it's here.
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Permalink Reply by Richard P Cosgrove on -
I am type 2. I got my pump in 2009. Actually it was my Endo's office that asked if I would like to use the pump and that according to BCBS, I met all their criteria. Only to 1 week to get the pump approved and had it hooked up in two weeks. FYI, according to my Endo, the insurance company has all the criteria that was brought up in previous post but that you only need to meet at least 4 of those to qualify.
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