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 This time, my request was "withdrawn" by my medical group and I was told to first meet with the CDE so that she could determine if I should be recommended or not.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 silver on -
Ok, so I spoke to someone from Medtronic & was told that I have to switch to another medical provider so that they can help me. She said, "getting the insurance to approve it should not be too difficult, but you need a medical provider that is willing to sign off on that and right now you don't have that."
So there I have it...I need to find a new provider! Uggghhh!
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Permalink Reply by still_young_at_heart on -
Someone suggested asking for a referral to an endo. That would be the way to go if you like the primary care that you're receiving from the practice. Most new/newish T1s benefit from an endo so tht is a reasonable request that shouldn't annoy anyone.
Maurie
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Permalink Reply by silver on
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I did see an endo once several yrs ago. He wanted to see me back, but my PCP had to make another request to approve the follow up visit. That was denied because I showed that I was doing well. I didn't question it much back then, but now I see that this should have been my first sign to finding a different provider. I'm happy to have found out that my kids & I can b under different medical groups. I guess it's my fault for assuming otherwise & not looking into this sooner. But yes, thank u, I'll make sure to request that an endo be part of my regular medical care wherever I end up.
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Permalink Reply by Kimberly on -
I agree with others who say this - you need to find an endo. That is how you get your pump. All they do is fill out a form saying it's a medical necessity for you, and bam - you're approved. If you have to have a referral to an endo (my insurance does not require that), then you need to find a new intern/PCP now so you can get a referral.
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Permalink Reply by dep on -
If you live close to where I live (North Chicagoland) I can give you the name of my Dr. who, with the help of Minimed, got my pump and CGMS approved and delivered to me in 7 business days!
There is no good excuse for a Dr. to not help you get a pump unless they believe in good faith that you will not be able to use it correctly.
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Permalink Reply by palomino on -
What a mess.. my GP and CDE are more than willing to sign off for me to get a pump. I went to an endo about 4 weeks ago and tried to get along with his PA, but it became very obvious that we have different personalities.. (she told me I was going to burn out testing the 8 to 10 times a day that I was testing in addition to other issues..) But they are the only endo group in the whole area.. I've just decided to stay with my GP... so you don't really *have* to see an endo, but at least change GP's!
And I'm not saying that my CDE knows everything about diabetes.. but she's been doing this for a long time... I actually e-mailed her to ask about some insurances requiring you to have an A1C less than 7.0 to get a pump, and she said she'd never heard of that before!
Sounds like the practice has just come up with their own rules... and I wonder if it somehow relates to the fact they probably see more T2's than T1's? I dunno.. no matter how we try to make sense out of it, it's obvious something is screwy.
I'm just sorry you've had to wait so long! It seems very unfair to me.
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Permalink Reply by silver on
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Thank u for asking you CDE about that for me. I'm glad to know that this 7% thing is not a universal standard as they claim. This medical group has several clinics, doctors, specialists, etc under it, but she's the only CDE & she told me that she only has a handful of Type 1 patients. So maybe this 7% rule does have something to do with seeing more type 2s than 1s. Who knows?! She told me that there is one other guy who has been trying to get a pump due to hypo unawareness (even got in a car accident once with his baby in the car) but was also denied due to being below 7%.
I did call yesterday to ask about some kind of an appeal process and am still waiting for a call back. I've started looking for a new doctor but don't know how to find one who is well versed in type 1 & able to meet my needs. I don't know any one else with type 1 or anyone on a pump for that matter so asking around wont help.
Anyone here in the Los Angeles area?
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Permalink Reply by Cherise on -
I was thinking about something. In 2010, I seen a CDE that said the recommendations were you had to be under 7%. I got my pump in 2011 after giving birth to my son and my A1C was right at 7 if not a little above and that was only because the rise in blood sugars at the end of the pregnancy. I was approved right off no problems at all. Though we had met our deductible and it was 100% covered. At that time it was BCBS now I have cigna and now they tried to fight me on covering my OmniPod supplies but couldn't since I was already on the pump. Not sure why they tried it though. I seem to be stuck at 7% though for my A1C and that's testing 8 to 10 times per day. No idea why.
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Permalink Reply by christy on -
Do you need a referall from your PCP to go see a specialist? If not then I'd start calling around different endo practices, you REALLY want an endocrinologist in my opinion. Some PCP's may be ok for managing D, but in my personal and professional opinion, most are really behind on the most up to date methods of treating D. Healthcare is becoming more and more specialized, and when you are dealing with something as complex as D, you really want someone who is specialized in the treatment and management. Not a Dr who has just dabbled in it. I would think living in the Los Angles area you'd have several endo's available. If you don't know anyone to ask, start shopping around, make that first appt like an interview. If you don't have good fuzzies or don't see eye to eye with how they wish to manage you, move on to another Dr.
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Permalink Reply by Bethanne Strasser on -
I agree with this. Medicine is so specialized!! Important to ask, even on that first phone call, if the doctor handles Type I diabetes. In the past I've ended up with an Endo who didn't see or manage Type I very much. Mostly, II so that I felt like I was always explaining things to the staff. Nurses, especially because they didn't understand why I'd be checking my BG more than four times a day. LOL :D Anyway, I read Kerri's blog once about that first appointment being like an interview. That really hit it for me because I was tired of going to doctors basically just to get the Rx I needed, but ignoring most of the advice offered.
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Permalink Reply by silver on
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You're right. I basically use my PCP to get my prescriptions and other routine bloodwork, etc. He doesn't look at my meter, doesn't ask about lows or highs, nothing. He doesn't even know about carb counting!!! I think I wrote this somewhere in this thread already, but basically, he initially put me on 5 (or 10...don't remember exactly) units of humalin 70/30, twice a day, plus check my BG twice a day only. I know, I know...I shoulda ran away then, but I didn't. He's not a good diabetes doctor by any means, but he listened to me and prescribed what I wanted...humalog, lantus, and 10 test strips per day. That was "good enough" for me I guess, but I'm sure that a doctor well versed in my medical condition would be far more beneficial to me, especially in the future when getting a prescription refill may not be sufficient medical care for me. Oh yeah, and not to mention this pump approval issue I've been having since 2010! Ha!
I'm interviewing candidates now for endo and PCP for me. Anyone interested in the position? :)
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Permalink Reply by Cherise on
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I was approved for the pump and have had one since October 2011. In 2010 I wasn't able to afford the cost of the co-insurance. They tried fighting me on my supplies but they realized I was already approved so there was no use in fighting with me and my endo about it. I've never seen anyone else other than an endo since diagnosis in Oct 2000.
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