Punished for good behavior...A1C

[quiltinmom]

The good news is that DS's A1C was SUPER! 6.2!!!!!!!! I thought it would be somewhere in the 6.7 range.

So, the bad news is the dr. said it makes it a lot harder to get a pump. He said there's "about a 30% chance" the insurance will approve it with such a good A1C. Dr. said he would appeal, but didn't sound too hopeful.

DS is getting more and more anxious about pumping...I hate to disappoint him.

My question is, is there anything I can do (paying out of pocket is not possible) or are we at the mercy of "the system?"

Thanks!

[McKenna'smom]

I say go ahead and try to get it. It may depend on your insurance company on whether or not they will deny it. I requested one through Animas and they got the doctor's script and handled the insurance for me. My DD had a 6.something A1C at that point and she got the pump with no problem. I don't think getting or not getting the pump approved should be based solely on an A1C.

[caspi]

I don't understand insurance company logic. The pump is just another form of insulin delivery. Why they would reject it is beyond me. Good luck and hopefully there won't be any issues.

[3kidlets]

Our insurance company didn't even ask for an A1C in the paperwork that the dr. had to fill out for the pump.

[obtainedmist]

I would think that the doctor doesn't make the determination about pumping...the insurance company does. As long as he writes a letter stating medical necessity, I would think it could fly. There is more to the story than the A1c. He could speak to avoiding burn-out and maybe some psychological points that would make the pump a better match for your son. Some insurance companies don't make you jump through the hoops. You can always submit the request and even if you get denied (which we did initially), you can appeal the decision. I hope you get more good advice from others who have gone to the pump with good A1c's. It just doesn't seem fair and I firmly believe that there will be a way for you to get approved! Fingers crossed!

[caspi]

Or perhaps the doctor was confusing the pump with a cgms. I can see an insurance company perhaps balking at a cgms with that A1C number. Who knows with insurance companies!

[Flutterby]

There should be no reason why you can't get a pump with a good A1c. Pumping shouldn't be just for 'better control', its simply a different way of delievering insulin. If he wants to pump, then he should be able to pump. With that low A1c you could always say its from to many undected lows because you can't accurately dose him with syringes. Definitely go for it and if it comes to appealing there are ways around it... I don't hear of to many people that are denied a pump. Most states have mandates of the insurance companies HAVING to cover pumps.

[frizzyrazzy]

I guess that is such an outdated way of thinking - that a pump is used only for people who have REALLY bad control. Maybe that was once, but it isn't now. We see here people on pumps with horrid a1c, and people with MDI with great a1c.

sure, pumps can be a tool to help people get better control, but they can also just simply be an alternate delivery method that one picks due to preference.

Why the insurance companies put up these roadblocks is beyond me.

[hawkeyegirl]

I guess it's possible that it might take a little more work on your part, but I wouldn't worry about it at his point. Our a1C was in the 6s and we got a pump (and CGM) with no problem.

Submit the paperwork and see what happens.

[jules12]

I say go for it! You never know until you try. If they deny it and you really want it - appeal appeal appeal!!!!!!