Replies to This Discussion

Permalink Reply by Kate's Mom on January 13, 2013 at 3:12pm

http://www.ncsl.org/issues-research/health/diabetes-health-coverage...

Each state has different mandates for coverage. The link above is a good place to start to see what is mandated for your state. From my experience, Medtronic pumps are usually covered by insurance to some degree. The following is a pdf of united health medicare adv. plans revised in 2011. Hopefully this well help.

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en...

Permalink Reply by Matt on January 13, 2013 at 4:57pm

Thank you, very helpful.
Matt

Permalink Reply by Natalie ._c- on January 13, 2013 at 6:02pm

Last time I checked (and it could have changed by now), Medicare determines your eligibility for a pump by your C-peptide. You have to be less than 110% of the lower limit of normal. Many T2's don't meet that criteria, and if so, Medicare will not pay for ANY kind of pump for them. But of course, I don't know what yours is, so discussing that with both your benefits manager (or whatever they're called) and your doc would be the place to start. I know how anxiety provoking this is, so you need to go get the needed info and get the process going ASAP! Good luck!!

Permalink Reply by Matt on January 13, 2013 at 6:45pm

Thanks, Natalie. You are right about meeting c-peptide criteria, but I read the attachment from Kate's mom above and found a statement that said if I've bee on a pump for 6 months at the time of medicare coverage that I would be exempt from that. I can only hope as my level is 3.2 and the range was 1.1-4.4. Hopefully I will know by Tuesday.

Permalink Reply by Natalie ._c- on January 13, 2013 at 8:18pm

Well, I looked up the document, and it said criterion A or B, AND C or D.

It's the AND part that's going to get you:

Criterion A says either a or b AND c: a)the C-peptide less than or equal to 110% of the lower limit of normal or b)200% in the case of renal insufficiency and c)fasting BG less than 225. If your level was 3.2, then you don't meet that criterion.

Criterion B says beta-cell antibody test is positive. If you are T2, then you would likely not be positive, although your doc can TRY that test. But it's very unlikely to come out positive.

Criterion C is diabetes education, and Criterion D is having been on a pump before.

So while you do meet Criterion D, you don't meet either A or B, and that's what will keep them from paying for your pump. I'm sorry to be the bearer of bad news, but on the other hand, that's what the document says. :-( And not that it's going to console you any, these regulations were written specifically to keep T2's from getting pumps, because Medicare didn't want to spend all that money since there are so many T2's. :-( :-(

Permalink Reply by Fighting for Stephany on January 19, 2013 at 7:48am

I was informed that medicare and medicaid no longer uses c-peptide levels as a determination or approval for a pump, they are focusing more on your A1C levels and high sugars. Calling the pump company and asking for information can also help, due to so many changes in the system it's better to ask. In Florida it's different and the requirements for approval doesn't include a c-peptide. I just got mine a couple of days ago, now I'm waiting for training and an educator to help begin that journey of pumping.

Permalink Reply by Matt on January 19, 2013 at 4:42pm

Thank you so much for your reply. You have been the only bright spot in my hopes of getting my new pump. I know my BG levels are high and my last A1C was 8.2 so if you are correct I'm hopeful. Has anyone else have knowlege of these new regs?

I am in NY so maybe Florida is different. Although Medicare is Federal and the same for all in US isn't it?

Matt

Permalink Reply by Fighting for Stephany on January 19, 2013 at 9:06pm

I got mine right away, my doctor did the request and 2 days later a DME company contacted me and requested the doctor to fill out the order form and send 2 A1C's and 3 month's of my logs and 2 chart notes. They submitted it to my insurance and the next day it was approved, got my pump 2 days later. Be positive, if you had Omni Pod already than changing shouldn't be an issue. United Healthcare is supposed to be one ofe the good insurances for medicare patients. Stay positive my friend everything is possible, let me know how it all goes and if I can help, it's always good to have a friend.

Permalink Reply by Matt on January 20, 2013 at 3:36am

Thanks so much, I appreciate your kindness and good thoughts. Are you type 1 or 2?
Matt

Permalink Reply by Rusty Plocheck on January 14, 2013 at 2:37am

When I got my Medtronic pump, I had no problem getting it through United Healthcare. Went right through and I had my pump shortly after they approved it.

I did find out something about Medtronics the other day, if you are on total disability you can apply for financial assistance. The number to call is 800-646-4633 and select option 4. I am calling them today to see what hoops I have to jump through with this.

Good luck

Permalink Reply by Matt on January 14, 2013 at 5:25am

Thanks Rusty. I am totally disabled, I will call today.

Permalink Reply by Matt on January 25, 2013 at 5:43am

United Helthcare Medicare Complete PPO has DENIED coverage for my new Medtronic Pump. Said my C-Peptide was out of range. Dr. is going to appeal, can only hope they change their decision. So upset I can't think straight :<(