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Aetna's Pump Policy - any luck getting pump prior to 6mo post dx?

Discussion in 'Parents of Children with Type 1' started by Christy Putnam, Jan 15, 2010.

  1. Christy Putnam

    Christy Putnam Approved members

    Oct 21, 2009
    I am curious if anyone on Aetna Ins has tried to get a pump prior to being dx'd for 6mo.
    Why i am wondering: Aden's endo office (3 different people) first told me it should not be a problem even after i went over the guidelines Aetna referred me to when i called prior to discussing pumps with his staff. They each mentioned some kind of appeal letter that he sends to all ins companies if they deny it.
    So on that news, I did research on which pump would be best for us and presented my decision to the dr/team. They are big MM people and i was worried about telling them i wanted the Ping for Aden. It was not the fight i thought it would be - just told me that i would have to get someone to educate me on it cuz they wont get certified.
    Therefore, i filled out the info to start the process of getting him a Ping. Aetna sent Animas a form letter saying the pump is approved "when the patient meets criteria" - which means when Aden has been dx'd for 6mo. Animas tried to get them to do a medical review but the same letter was the result.
    I then asked the dr office if there was anything they knew of to help, at that time they said "i havent ever had anyone cleared to get a pump prior to meeting criteria."
    I had an opportunity to talk to an Aetna nurse regarding Aden on another matter and asked her for the reasoning behind a T1 having to wait 6 mo. for a pump. She said "I was not aware of that. I will find out for you" She called me back, referring me to the same document i read in the first place which doesnt state WHY or differenciate between T1 or T2 in regards to pumps.
    So, i have come full circle and am left wondering if the dr would be more proactive had i chosen MM, if there is any real reason to have to wait 6mo, if it would be worth it to fight for a pump sooner or just wait until April and hope we get one earlier in the month rather than later and if anyone else has had this issue and came out successful?
  2. Flutterby

    Flutterby Approved members

    Nov 11, 2006
    The ONLY reason I know of to wait 6months is that you need to really know how to give injections and figure out dosages on your own before using a pump, just incase there is EVER an emergency where the pump wasn't working.. Having said that there are people who come out of the hospital on pumps and Kaylee went on a pump 4months after dx, they wanted her to wait a year (the dr's office, insurance had no problem.) but because she was so little and had such large ratios/ISF and such low basal (1/2u of lantus) it was really difficult to manage her. We know how to draw up insulin in a syringe, but honestly, its been over 3.5 years since she was on MDI, so going back would be extremely difficult (for me.. probably not for her..)

    Sorry you are having this issue.. I think having the 6month rule at the endo is so much easier than over coming the 6month rule at the insurance.. they are just going to do what they want.. which isn't the way its suppose to be..
  3. Christy Putnam

    Christy Putnam Approved members

    Oct 21, 2009
    I do understand that reason but 3 months is extremely adequate time frame (IMO) when you are doing (at least) 4 injections/day. 6 months is over-kill and just down-right cruel to make a child endure it for that long just because someone says so. I also would have less issue with it if the endo's office hadnt set the expectation of it being 'no problem' and having 'a certain appeal letter' then turn around to tell me otherwise...we were hoping to have the pump during Aden's 5th bday month (Jan) - what a let down for him.
    I know April will be here relatively soon but the poor guy could really use a break from getting poked all the time.
  4. sarahspins

    sarahspins Approved members

    May 5, 2009
    Have you started the appeal process with your insurance yourself? Talked to HR with your employer? Sometimes if you get them on your side it makes things happen faster. Don't leave it up to the pump company - start making some noise :)

    Get a letter of medical necessity from your endo as well.. the pump company has one, but maybe you could have them write a more specific one for the insurance company.
  5. McKenna'smom

    McKenna'smom Approved members

    Jan 5, 2010
    We are also with Aetna and were told by our endo that we would have to wait 6 months. Our endo office prefers Animas. We decided not to appeal it and just wait. We are going on a 10 day vacation at about 6 months out from DDs dx so we thought it would be best to wait until we get home to start that new experience and have the summer to get used to it before school started again.
  6. candise

    candise Approved members

    Feb 11, 2009
    Have you called the insurance company and asked directly? We were told 6 months by our endo and at month 3 we were ready. We started pumping at month 4. I think every situation is different.
  7. fuddster

    fuddster New Member

    Oct 8, 2009
    We've got Aetna too

    We're going through the same thing. We were told 6mos by Aetna and the endo, although when we pushed the endo she said it could be as early as 4mos.

    But we're deciding to wait as well as spring break is just over 6mos and a good time to get all of us accustom to the new way of life. It's going to be close though so I'm going to start the process early and see what happens. I fully expect that I'll have to appeal just to get the pump "on time".

  8. fredntan2

    fredntan2 Approved members

    Apr 21, 2007
    april we be here before you know it.

    What does the animas rep think? they should be able to help you.
    have you done a saline trial on the pumps?
    had all the pump reps come to house to make sure this is the pump for you?
    animas will be releasing the new integrated pump with dexcom soon. hopefully it shoulld be out by april.

    they made us wait a month back in the old days (4yrs ago) couldn't even get a endo to agree to write order. so glad they are changing there policies for shorter waits.
  9. goochgirl

    goochgirl Approved members

    Jul 28, 2008
    The passive aggressive in me says to call Aetna every day and speak to every person you can just to make some noise. What? Do they think its going to go away?? Make them justify their (nonsense) reasoning.
  10. SarahKelly

    SarahKelly Approved members

    Nov 14, 2009
    we have Aetna, our son was diagnosed on Nov 8th and started pumping on December 17th. However, his age maybe why they authorized it so early. He was only 19months at diagnosis.

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