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UHC denied dd's tslim

Discussion in 'Parents of Children with Type 1' started by Kaylas mom, Dec 26, 2014.

  1. Kaylas mom

    Kaylas mom Approved members

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    Did anyone else go through this? I am livid since her medtronic pump is out of warranty, has a crack in the battery compartment and now UHC says that a new pump is medically unnecessary. The endo is setting up a peer to peer consultation with UHC's medical director but there is no way it will be done before the end of the year. I am sure they don't want to shell out any more money to us this year since we already met our out of pocket. 8K we have paid out this year for other medical issues and just met it about a week before they denied the pump. Figures.

    I can't figure out if it is the tslim they are denying or a new pump in general. Does anyone have experience with this?
     
  2. Nancy in VA

    Nancy in VA Approved members

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    Did your endo write a letter of medical necessity with the prescription? They require that. You need to find out ASAP the reason for the denial so you can fight it properly. Until August, UHC didn't have an in network provider for the pump but now they do. You need to find out if the denial was just because of working with the wrong provider. Did you work directly through Tandem? They worked hard over the summer to get the in network provider - it's Byram healthcare. So my recommendation is call UHC and/or who tried to process the prescription and get the specific reason for denial so you can address it with the right answer.
     
  3. Kaylas mom

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    Yes, the endo sent a letter of med necessity (twice) I guess. We were going through Diabetes supply or something like that, they are part of Byram. I just talked to Tandem and they felt if the endo could get the peer to peer by Monday then they still might be able to get it billed to the insurance by end of year. Fingers crossed!

    Oh.. they denied stating lack of medical necessity.
     
  4. Nancy in VA

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    We got our t:slim covered at our regular DME rates by UHC in August. We had been denied before in May due to lack of provider but then on August they got Byram on board (yes, DSC and Byram all the same now). There are different levels of coverage and plans - we have a pretty basic one. Some have UHC Choice but we don't. Once Tandem got Byram in place, we got our approval in about 5 days and that was only because they have a huge flood of new orders at Byrsm from UHC patients. Good luck - that denial makes no sense since they have covered it for patients. When was the Medtronic bought? I've heard that they have denied paying right after the warranty expires (usually wanting to add at least a year) unless there was a malfunction with the existing pump. Do they know her existing pump is broken and being out of warranty, can't be replaced - and that you aren't just asking because the warranty is up?
     
  5. Beach bum

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    UHC should still OK it. We just got a new pump, switched from Animas to MM while still under warranty with Animas. Reason being is that the Animas didn't hold enough insulin. UHC didn't bat an eye at it.
    Also, with Byram, make sure you are using the correct dept. Ie. DME vs. pharmacy. I would also ask the T-Slim rep to step in and help you navigate the insurance waters. MM did everything for us. I never had to do anything other than fill out the paperwork.

    Good luck and I hope all of this is done prior to the end of the year!
     
  6. RomeoEcho

    RomeoEcho Approved members

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    I would suspect DSC being your problem rather than UHC. UHC approved my slim no problem with an out of warranty non functional pump, but Ive had lots of problems with DSC every step of working with them. See if Tslim can get you approved and then filled by DSC. Also call UHC directly and see if they will give you an explanation for the lack of necessity. It might be easy to clear up.
     
  7. Kaylas mom

    Kaylas mom Approved members

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    Thank you, I will try and call again today. Her pump is just out of warranty (a month ago) and we didn't notice the crack until the endo's office asked if there was anything wrong with the pump that they could use as reasons why she needs to change now.
     
  8. Jordansmom

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    I agree that its entirely possible DSC is the problem. I have had nothing but problems with them. Multiple times, I have had customer service reps flat out lie to me when they forgot to process something or did something incorrectly. They would say they were still waiting on insurance approval and it was out of their hands and when I called them on the lie they admitted they "misspoke" and they really needed to fix something they had screwed up. Even if your insurance has denied the coverage it could be that DSC has done something incorrectly. I'm not saying the problem isn't your insurance. Just make sure you are independently confirming any info you're getting from DSC. In a time crunch, Tslim will undoubtedly be a better advocate for you than anyone at DSC.
     
  9. BrendaK

    BrendaK Neonatal Diabetes Registry

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    We've also had horrific service with DSC / Byram including the reps flat out lying about issues. Not one time did they get any order correct ever. We've switched everything over to edgepark and it's been smooth sailing. Good luck.
     
  10. Megnyc

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    I have also had nothing but problems with DSC/ Byram. They completely messed up getting me the dexcom when I first ordered it about 1.5 years ago. Then when I needed a new receiver they again lied to me multiple times about insurance issues and essentially invented a bunch of roadblocks. They were saying it would take at least 2 weeks to get insurance approval. I called a different place and it was approved while I was still on the phone and shipped out that afternoon. If you have UHC Choice Plus, I believe you shouldn't have to use DSC. At least I didn't when I was going to get a tslim. I would have been able to go directly through tandem and this was a few years ago too, when it was more difficult to get the tslim covered.

    ETA: My experience with UHC is that it is no issue to get a pump approved quickly. I have never had it take more than 24 hours for approval. I think I have gotten at least 3 pumps through them over the years. All plans have been UHC Oxford PPO of NY though, so it may differ by state and HMO vs. PPO.
     
  11. Nancy in VA

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    Strange to hear all the problems with DSC. I've never had a problem and that includes needing to get our last Dex approved before our deductible end in June. Then when they shipped it, it was due to arrive signature due when we were on vacation. I called and the woman offered to reroute the shipment to go to our vacation hotel and ventilate decided to cancel that shipment and send a new one overnight so it would arrive before our vacation. Byram was also very quick to process my pump order once they were authorized for UHC. I had to make one call to get someone to pull it off the pile bit then I had it in less than a week. I wonder why the service is so different.
     
  12. Beach bum

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    We've only had minimal issues with DSC. They said they had to delay new transmitter shipment, but gave no details. I didn't think much about it since ours was still working. I do get annoyed because you can't do anything online with them, and they send out too many bills, causing confusion. Byram sends one out, then DSC.
     
  13. Kaylas mom

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    Wow.. very interesting. I hope this isn't the case since we are switching from MM because of their horrible billing issues. Tandem has been really helpful but it sounds like it is a UHC issue. I hope by tomorrow the endo has talked to them. Tandem said if they do there is still a chance getting it covered this year.
     
  14. Kaylas mom

    Kaylas mom Approved members

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    Update!!!!

    UHC overturned their denial!! Thanks to the super hard work of Tandem, they called and demanded a peer to peer to be done immediately and Kayla's endo was unavailable so the CDE from Tandem (who we have met here locally) stepped up and took over. Last night they said they would have a decision within 24 hours and they just called and approved it!! DSC already processed the order just minutes ago so it is officially on this years deductible! I can't even tell you how overjoyed I am right now. That would have cost us $3000 out of pocket if they hadn't gone so far above and beyond.
     
  15. Melissata

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    That is great news! She will love the pump, and customer service is always top notch, not just when it makes them money.
     

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