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Freaking out, just a little bit :(

Discussion in 'Parents of Children with Type 1' started by Noah'sMama, Sep 20, 2012.

  1. Noah'sMama

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    So happy day! Noah's pump came today. Unfortunately, I also received a letter from Tricare DENYING coverage for it. They said that there wasn't sufficient proof that his current therapy isn't working. I don't know about you, but that sounds to me like they think that he's TOO well controlled, which has to be one of the stupidest things I've ever heard. We work our tails off to keep him well controlled. He has a lot of lows because of it. He also had an a1c of 11.7 just in February because he WASN'T as well controlled as he is now.

    So I have the pump. Should I worry that I'm going to get an enormous bill now? What about supplies? I'm worried and I know I need to call Medtronic, tricare, and his doc tomorrow, but tonight, I'm freaking out. Any advice? Am I overreacting? The letter was dated 2 days ago, and Medtronic called me on Friday and told me it was approved!?!?
     
  2. MamaC

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    Breathe. Make a list of the calls you need to make, and the points you need to address, and in what order. Then breathe.

    Brush your teeth, massage your temples, and breathe.

    Climb into bed, turn off your brain, and breathe.

    You will have a plan, and you will tackle it in the morning...while breathing.

    Good luck!
     
  3. misscaitp

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    What Tricare region are you in?
    First I would make sure that your doctor did do the pre-approval, which is required for any device valued over $2,000. The two pump companies I have worked with sometimes jump the gun by saying that it will be covered 100%, but without the pre-approval not much can be done.

    Also I would find out what the doctor put for that pre-approval. I know with my clinic they'll put down any little thing that could be viewed as a complication. So I've had protein in my urine, they'll put something about microalbuminria (sp?) or if I have multiple lows or unexplained highs (dawn phenomenon) theyll put that.

    I would say it was either a breakdown in communication or an error. I would start with tricare just to make sure it was actually denied. If it was contact minimed while also starting the appeal process with tricare. Also contact the doctor.
     
  4. Mish

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    It sounds like someone just goofed. Tricare has been covering pumps (in full) for a long long time.
     
  5. Noah'sMama

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    I called medtronic this morning, they said they hadn't received the letter yet but when they did they would send the documentation that tricare needed. She couldn't tell me anything about the supplies though, just that when the appeal was finalized they would let me know how much I'm responsible for. I haven't called Tricare yet, but I will later today. I think it's going to be ok, at least for the pump. I'm just a tad concerned about the supplies now, lol. But not too much.

    He starts the pump on Monday! VERY excited, it's been a long time coming.
     
  6. Mish

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    if you have tricare prime they'll be covered in full. 100%.
     
  7. misscaitp

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    It pays in full only if you qualify for the pump. I've checked the standards before, and it says that to qualify you have Type 1 Diabetes which is uncontrolled. A lot of the MD reviewers tend to give the pump anyway based on the doctor's suggestion, but if you have a stickler reviewing your case they do have grounds to deny you.
     
  8. Noah'sMama

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    well, he routinely runs below 50, and hits the high 30's a few times a week, plus I test him 2-3 times a night due to his lows. Seems like that would count, in addition to artificially lowering his a1c.

    That's a stupid rule, anyway. Way to encourage discipline, lol. Seems like it would encourage families to neglect care in order to qualify for a pump. Like I said, his a1c was 11.7 just in February.
     
  9. Flutterby

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    Medtronic won't send a pump without the approval of the insurance company first.

    We got a denial letter in the mail the same day MM called me and said that her pump was approved (different insurance though). I wouldn't worry about it.
     
  10. Flutterby

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    All the dr has to do is check the 'uncontrolled' section of the paper. Kaylee's dr routinely does this even though she's considered controlled because insurance company will nit pick of the stupid stuff, it IS easier to get coverage for things if you are uncontrolled.
     
  11. buckmarko

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    What region are you in? I know that the regions are all different. We are North and they didn't hesitate at all with us. Tricare is covering our pump 100% in less than a year after diagnosis. When I was looking into getting a pump, a person had to be diagnosed for 6 months. If you are active duty, there shouldn't be any OOP costs. Also, with those kind of lows several times a week, he would be eligible for a CGM, if you don't already have it. You just need the correct documentation (which the sales reps are very good at). Does your pump have the CGM built in? (That's if you are interested in the CGM).
    Keep us updated.
     
  12. Noah'sMama

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    We're TriWest. He's more than a year from diagnosis, his 1 year anniversary was in February. CGM is our next step, they sent us the Revel and his endo already sent in the paperwork for the sensors. They just want us to wait a couple of months after starting the pump to get it.
     
  13. Mish

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    That isnt' entirely correct. The standard is this: "Documentation of type 1 and POOR control." And all that is required is the physician checking a box saying that is the case. That's a totally arbitrary call on the part of the endo. "poor control" can be whatever the endo decides it is.

    It isn't asking for documentation of the official code of "uncontrolled diabetes".
     
  14. Mish

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    and here it is from the triwest website: (bold and red is mine)

    http://www.triwest.com/en/provider/clinical-information/clinical-guidelines/insulin-infusion-pumps/

    • External insulin pumps and medically necessary supplies may be considered for coverage if ONE of the following requirements is met:
    • Cystic fibrosis-related diabetes with fasting hyperglycemia
    • Gestational diabetes
    • Type 1 or 2 diabetes mellitus during the pre-pregnancy phase or during pregnancy
    • Type 1 or 2 diabetes mellitus (including latent autoimmune diabetes) with ALL of the following:
      • Treatment regimen includes three or more insulin injections per day with frequent self-adjustments of insulin dose during the six months prior to initiating the insulin pump Yes
      • Documented frequency of glucose self-testing is an average of at least four times per day during the two months prior to initiation of the insulin pump Yes
      • Glycosylated hemoglobin A1c (HbA1c) level has been completed within the recent three months Yes
      • Unstable blood glucose levels as documented by ONE of the following:
      1. Glycosylated hemoglobin (HbA1c) greater than 7.0%
      2. Recurrent hypoglycemia Yes
      3. Wide fluctuations in levels over the past 2 months Yes
      4. Dawn phenomenon with fasting blood glucose levels greater than 200
      5. Severe glycemic excursions requiring emergency room care or inpatient admissions within the past 12 months
      6. Comorbidity resulting from diabetes (such as nephropathy, kidney transplant, neuropathy, retinopathy, gastroparesis)
      • Patient has demonstrated compliance with the treatment regimen including diet, blood glucose monitoring, insulin administration, and insulin dose adjustment
     
  15. Sarah Maddie's Mom

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    Nice work ;)
     
  16. Noah'sMama

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    you covered it pretty well :) I remember answering these questions, too. Thanks!
     

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