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If you use an insulin pump, have you ever received a denial from your insurance company, notifying you that the costs for your pump and/or its supplies will not be covered? If so, what was the reason? Please select all that apply to you, and share in the comments about your experiences.
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The PA is required once/year…even though T1D is incurable.
The first time it happened, I had just been diagnosed, learned the ins/outs. Now it’s automatic and I have this year’s ready to go for my Dr as I type!
This was from back in the day when pumps were new. I had to have an endocrinologist verify it was medically necessary. Took some time to find one, but I did. Then the paperwork was insane and was still told I could get a rejection. My A1C was bad and finger prick tests did finally win over the insurance company and I did receive a pump. I am glad the process has become easier, I just know I have to wait until a medical device is something that has been shown to work and is a normal procedure for the diabetic community. The last time I went through this was the closed loop system. My endocrinologist now is a master at getting things taken care of so it is less stress on me.
I probably clicked the wrong response. But, as I’ve told before, I was denied getting a CGM by my insurance company around 2006. I was told it was not a covered item. Soon afterward, I collapsed from a low blood glucose and broke my ankle. I called the insurance company while I was sitting at home in a cast. I told them that I probably would not be home from work, costing them thousands of dollars if I had a CGM. Soon afterward, I was approved by the insurance company for a CGM. I may have been the first person approved for a CGM by my insurance company (I can’t prove that).
UnitedHealthcare had an exclusive contract with Medtronic barring my request to get Tandem pump. I was able to get Dexcom Sensor at least and get away from that ridiculous Threshold suspend on the very unreliable Medtronic sensor. Changed to Blue Cross Blue Shield to get Tslim. Now Dexcom/Tandem combo is working well with the CIQ. Much better control.
Same! I was so mad, and my doc didn’t want to hassle with the paperwork to fight it. I don’t blame her, I know she knew it would have been a futile effort. But insurance changed and I have been happily on Tandem for 2 years now.
As of January 2023, just about one year after the FDA approval of Omnipod 5, Tricare has not yet approved coverage of the newest model for military families. It was presented at a closed meeting in November and we may find out in February if it is approved—and then will wait another 60-90 days for it to be added to the Formulary.
Back in 2007 I wasn’t allowed to add the CGM to Medtronic’s system while on Tricare because it wasn’t medically necessary either. Didn’t add CGM to my care until 2012 when separated and had good medical insurance through my husband’s new job.
My doctor had to provide detailed info to justify the necessity of my first pump (1990s), such as work hours, dawn phenomenon hypoglycemic episodes or done thing like that, juggling a couple of toddlers, etc., which hasn’t been necessary since then. However, when I started with health care coverage under Medicare (USA, when I retired), I had to prove I had T1D to get coverage, despite having had T1D for 50+ years with ample medical records to document that history.
Yes, but not recently, thank goodness. However, when I was first prescribed a pump in 2000, I had to go through several rounds of appeals with the insurance company to justify that it was medically necessary. I wrote a detailed letter essentially saying “is being found unconscious due to severe hypoglycemia requiring glucagon ~4x/yr and an emergency room visit not adequate justification? Finally, convinced them by making the case that a pump was good for us both (reduced risk of premature death for me AND less costly for them). That worked. Have been pumping since Sept 2000.
I paid out of pocket for a Tandem pump as Medicare doesn’t pay for new pumps sooner than 5 years. My Medtronic pump had had numerous manufacturer issues and I just wasn’t getting acceptable control. I wasn’t eligible for another 18 months.
I think I’ve mentioned this before, but my first pump request was denied at first as not medically necessary. They told me it would be cheaper for them to send a nurse to my house every day to give me injections if I had no hands to do it myself. They caved after I told them I’d already paid the copay, which was quite a lot of $$ at the time. That must have convinced them that I didn’t consider it to be a luxury.
The Omnipod pump intro kit was “not covered” but the Omnipod’s are! I jumped hoops with help from Insulet for 6 months and finally received an insurance override. It shouldn’t be so hard!
I checked “yes” because they UNDERSUPPLY me. I get exactly 10 infusion sets per month. And fairly often, one either is irritated after 2 days, gets accidentally pulled out, goes in incorrectly, has to be changed early or I ruin it while trying to insert it with the delicate multipart procedure of unwinding the tubing, removing swivel tape, etc. of TANDEM) I have zero slack unless I wear them for 4+ days. Frustrating and stressful. If you call for replacement, its a long phone call and a week later, a giant box with one replacement (so much environmental waste!!). Dr. tried to write prescription to change every 2-3 days but alas insurance said NO.
Yes – not Medically Necessary – back in 2007 when I started with Medtronic the CGM portion was not medically necessary and not covered by insurance.
Yes – had’t seen my provider recently enough. 2 months ago I tried to reorder supplies, they needed a new Rx and chart notes. My chart notes were more than 6 months old so I had to get an emergency virtual appt and labs drawn to update notes before prior auth was issued and supplies sent.
Yes- pump brand not covered by insurance. Back when UHC was exclusively “in-bed” with Medtronic they would not authorize a switch to Tandem because it was not a covered device.
When I switch from private insurance to Medicare I was denied coverage. I had to prove to them that after almost 30 years that I was actually a type 1 diabetic and I had had that test back in the early 90s which proved it but I had to do it all again. it took 3 months to get it straightened out
I have had several of these reasons occur. when I first got a pump the insurance initially said it was not medically necessary. As time has gone on I’ve had insurance companies tell me that the brand/model I was using was not covered. One time more recently, I was told that I had not seen my endocrine recently enough, even though he had submitted a new prescription for me! I have needed a Prior Authorization every time my insurance has changed over the years except once! I also have had “clerical errors” (I forgot to check that one!) with my current insurance. They told me my pump/CGM were not covered when I had just received a letter in the mail telling me that they were, with Prior Auth. which had been approved. I guess it wasn’t in the system yet!
I selected “No – I have never been denied coverage for my pump or its supplies” but this MAY be misleading. I live in the United Kingdom of Great Britain and Northern Ireland where all of my diabetes supplies are paid for by our NHS (National Health Service), which is financed via direct taxation of all working people.
It was a long time ago, 1979-80. It was deemed experimental and they refused to pay. My parents sued and it was ruled in their favor. Since then I don’t ever remember having an issue.
I said yes, it was deemed not medically necessary. Some background detail’s important here: this was back in 1998 with my 1st insulin pump. The Minimed 507c. I had a HMO at the time and had to file an appeal which included pictures of my bruised abdomen among reports of the toughness on my arms & legs that prevented the continued use of MDI. After a lengthy fight, it was finally approved. Every pump since has been a piece of cake in comparison
A long time ago when I used a pump, but it was a severe comedy of on going ever changing pathetically untrue errors.
My favorite was in necessary.