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Qualifying for Pump

Discussion in 'Parents of Children with Type 1' started by Junosmom, Dec 8, 2013.

  1. Junosmom

    Junosmom Approved members

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    Our first appointment post diagnosis is this coming week. (We've met twice with the CDE, once for a pump class.) I was told by the CDE that usually, one has to have had two Endo appts. before you can get pump approval (not sure if she means the dr. approval or insurance, though my insurance said we have no waiting period) and that part of that waiting time is proving you've had certain experiences in diabetes management. We've had several of those she mentioned, and I'm making a list for our appt. For many reasons, I'd like son on a pump, and right now, I have my deductible met.

    Here is a list of some of those things we've experienced since diagnosis. Can you think of any other experiences they might want us to have had before having a pump?

    • Travel
    • Illness - cold virus
    • Holiday - Halloween, Thanksgiving
    • Visitors
    • Eating out
    • Changing Lantus time
    • Wore a trial pod for two days
    • Pump class
    • Snow
    • Lows - doesn't often recognize lows, was 60 today and only reluctantly tested "I'm fine, Mom!"

    I also would like to qualify for CGM and was told I would not qualify for that. You must show that he has many unrecognized lows. So, even though I know that eventually he'll qualify for a CGM (can you say "puberty"?) they make you wait?? I can show he has lows, doesn't wake at night, but not a lot of them. I'll push for this, too, but I'm not all that hopeful. Son doesn't really even want it, because of the tubing, but I'm educating him on its advantages.
    Thank you in advance. So thankful to be recommended to this list by a friend.
     
  2. Shopgirl2091

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    I think your list looks great. I don't even think you necessarily had to have all those things already to get a pump, but I think your want of it is the most important thing.

    If you want the pump, and you are motivated enough to learn what it takes and do what it takes there should be no reason they wouldn't give you one.

    As far as the CGM goes, I wouldn't be swayed by them telling you no on that either, it is your child and there are far more advantages to having one than just using it to catch lows.

    What I'm trying to say is, if you really want one, then don't let them tell you no. My doctor originally brushed my request aside saying that my son wouldn't wear it. I pushed and pushed and pushed until she listened to me, and even wrote a letter of medical necessity for us to get it.

    If it is your doctors office holding you back from getting one I would go to a different doctor, if it is your insurance company I would keep trying to get one. Just don't give up on what you want. It is your child and you are the one who is taking care of him - they should be helpful in getting you whatever tools you feel are best for his management.
     
  3. MomofSweetOne

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    If your son isn't waking at night, it's considered Nocturnal Hypoglycemic Unawareness and is a reason most insurance companies will cover CGM. Read the main CWD page for research articles showing the frequency of not waking at night is far more frequent that previously thought; attaching such information might be beneficial in an appeal if you get that far.

    Some pumps have tubing, but the Dexcom G4 is wireless.
     
  4. Don

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    Sounds like the endo has a process to ensure that people are ready to pump which really does have a learning curve. You might mention your year-end deadline so that is crystal clear. As for CGM part of it, my guess is the endo really doesn't know if he will qualify due to the various requirements made up by the insurance companies. Anyway, if your son is like most PWD who start on pump, he will much prefer it despite the tubing.
     
  5. MyHandsAreFulll

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    Push for what you want, remember your doctor works for you. We had our pump ordered before my daughter was out of the hospital at diagnosis. She started pumping 3 weeks post dx. We held off on CGM 3 months because we weren't ready, but if you are able to get it at 100% coverage, push for approval now. I believe you should be able to have all the tools at your disposal that will help you keep your child at his/her best. Good luck to you!
     
  6. quiltinmom

    quiltinmom Approved members

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    It is not unreasonable to think you could have a pump ordered/billed to insurance before end of year/insurance reset. Do push to get it ordered now, even if they want you to wait a little while longer before using it. :) you might be better off getting through the holidays on shots (because it is what you know, it is busy, etc.). Just a thought.
     
  7. Sarah Maddie's Mom

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    Here's what you need to "qualify" for a pump: You need to have Type 1 diabetes. :rolleyes:

    You realize that today people get dx'd on Tuesday and begin pumping on Thursday.;) You endo is being prehistoric. There's nothing particularly special about learning to pump, it's just an insulin delivery method, not a prize.

    I wouldn't take no for an answer. Just insist, and if that fails, find a new endo.
     
  8. Wren

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    Our experience: when we asked soon after dx, we got vague answers like this. But, when we asked for a pump by the start of school, and there were no group pump classes right away, they made us a private pump class appt right away. And 13 days ago, when I sent an email saying I'm ready for a CGM, the CDE called literally 1 minute later and said, "I have the medical necessity form in front of me." It is scheduled to arrive tomorrow.

    My point is to come prepared, but you might find they're really quite helpful once they clearly hear you're ready and the timing is good.
     
  9. Beach bum

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    All you need to qualify for the pump is diabetes.

    Our insurance made us wait until 6 months (I don't know, did they think it might go away?:p). So, that would be two visits. No issues what so ever from that point. We also were able to get it right at the 6 month mark (6 month, 1 day) so that we could fulfill our deductible that year. Training was scheduled a few weeks later (due to holidays and trainer going on vaca.).

    As for the CGM, that bull. You want a CGM so that you don't have unrecognized lows. If it's your endo telling you this, then fight. Or find a new doc. If it's insurance telling you this, have your endo write a letter of medical necessity. We have our CGM set higher so that we can avoid as many lows as possible.

    Good luck!
     
  10. Beach bum

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    Yes, this is what most do. However, by about month 2, we were more than ready for the pump. It's not unusual in some European countries for kids to be put on the pump right at diagnosis. Their hospital stay is extended a bit longer in order for the family to be trained.
     
  11. ecs1516

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    One you can add to list,
    Sports (like Cross country or soccer.) We use temp rates to decrease basal
     
  12. missmakaliasmomma

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    The real importance I believe is having a great endo. My endo was explaining to me that with my daughter's insurance, it's not likely that she will get a cgm but she also said they are trying really hard to change that and she's going to try to get it for my daughter anyway.

    I would definitely get the pump before the new year and a new deductible to be met.
     
  13. Junosmom

    Junosmom Approved members

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    Going for It

    We had our very first appointment with the Endo yesterday. (Two other appointments previousl were with the CDE.) I was pleased with the way he talked to both my son and with us. Son's A1C was 6.5 yay! (Down from 12+ at diagnosis less than 3 months ago.)

    We asked about both the pump and the CGM and he was very receptive. He asked our reasons. Son said because he sometimes is still hungry after eating and wants to eat more without taking another shot :) We, of course, discussed our other goals. He said he'd put in the paperwork and seemed positive about getting one. Told us we should go ahead and start learning and using it, not wait.

    I gave my reasons for wanting a CGM, and he recommended the Dexcom. He said he'd put in for that, too. He did not seem as negative about our chances for insurance to approve as the CDE was, but then the CDE may have more real life experience with insurance approvals. But, if he approves it, then I can fight the insurance company.

    Happy with Endo so far - and he's not the tyrant the CDE made him out to be.
    Oh, and I slipped and used the word "compliant" when discussing my son's wonderful attitude so far, corrected myself and said, bad word, I should say "adherent" and he said, "thank you for that". He noticed the difference and agreed. I thank the list for making me think about this choice in words.

    Thanks for helping me!
     
  14. Beach bum

    Beach bum Approved members

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    Glad it went well!

    Maybe the CDE and his styles are different, which is why she made him out to be a tyrant? Most important thing is you had a good experience and he is open and receptive to you getting not only a pump, but a CGM too. Good luck with the insurance gods!
     

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