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Insurance denied Omnipod

Discussion in 'Insurance Issues' started by Brends, Mar 31, 2008.

  1. Brends

    Brends New Member

    Joined:
    Mar 31, 2008
    Messages:
    3
    Please, I need some advice in writing our APPEAL.

    Today we got the dreaded "denied" letter from Anthem for our teen's Omnipod.
    Their reason :"not medically necessary" & "does not meet criteria" (which she DOES)

    Is this normal and do we prepare ourselves for a long fight w/ Anthem?
     
    Last edited: Mar 31, 2008
  2. Burlew

    Burlew Approved members

    Joined:
    Feb 4, 2008
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    Have you contacted your endo and the pump rep. They can help you with the appeal process.(I know that Omnipod reps. are used to having to jump through hoops) Good luck!
     
  3. CatiesDad

    CatiesDad Approved members

    Joined:
    Feb 21, 2007
    Messages:
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    CIGNA denied our request for a pump on 2 occasions. Sent in the following letter. Soon after the OP was approved. I know the Dr. also made a couple of calls at about the same time so I'm not sure what changed their position.



    March 22, 2007



    ATTN: Appeal Unit
    CIGNA Healthcare
    National Appeals Unit
    P. O. Box 5225
    Scranton, Pennsylvania 18505-5225


    RE: Patient Name
    Member: Name
    Member ID Number:


    To Whom It May Concern:


    Please consider this a formal appeal of CIGNA’s denial of coverage for an OmniPod System for my daughter, XXXXXXXXX.

    CIGNA’s letter (dated February 13, 2007) denied coverage of an “Omnipod insulin pump”, stating: “The following are considered not medically necessary because none of them has been demonstrated to improve health outcomes:
    - software or hardware required for downloading data to a personal computer to aid in the self-management of diabetes mellitus;
    - the use of an external insulin pump in type II diabetes mellitus;
    - a combined or integrated continuous subcutaneous insulin infusion and blood glucose monitoring system (e.g., OmniPod) in place of the use of a separate standard insulin pump and blood glucose monitoring system.”

    Your records should reflect that XXXXX is a seven (7) year old girl. Your records should also reflect that XXXXX has juvenile diabetes and needs to be injected with insulin four (4) times a day: before meals and bedtime. What your records probably do not reflect is that XXXXX is a seven (7) year old girl who has many interests and participates in a number of sports (soccer, gymnastics, swimming). More importantly, there is probably no information in your records documenting the extent that these physical activities affect her blood glucose levels, and ultimately, the amount of insulin she needs.

    Because of XXXXX's fluctuating glucose levels, her Pediatric Endocrinologist (Dr. XXXXXX) recommended that we look into alternative insulin delivery systems to better manage XXXXX’s juvenile diabetes. After researching the various insulin delivery systems available, we feel that the OmniPod System offers XXXXX the best of both possible worlds: greater blood glucose control by better managing her juvenile diabetes; and, despite having juvenile diabetes, the opportunity to have a more normal childhood.

    For XXXXXX, the OmniPod System will not only allow her to obtain the correct amount of insulin at the right time, but will also deliver this insulin with much less discomfort. For a seven (7) year old girl with a low pain threshold, this could be the difference between compliance and non-compliance. For a seven (7) year old girl with a serious lifetime health condition, compliance is a not an option.

    If you feel that you need additional information, I’m sure that Dr. XXXXXX (704-555-1212) would be happy to provide you with anything you need concerning XXXXX’s history.

    Thank you for your time and on behalf of XXXXX, I look forward to a favorable reply.


    Sincerely,
     
  4. Brends

    Brends New Member

    Joined:
    Mar 31, 2008
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    ;) you guys who replied, are awesome. I SO appreciate the help. Will post an update as soon as have one. Thank you !! Thank you !!!:p
     
  5. leslieJ

    leslieJ New Member

    Joined:
    Oct 13, 2007
    Messages:
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    good info!
     
  6. Brends

    Brends New Member

    Joined:
    Mar 31, 2008
    Messages:
    3
    Anthem denies appeal OMNIPOD

    Our written appeal by our Endo was denied today.
    Anthem Blue Cross/Blue Shield denied it because Omnipod is considered "investigational".
    However, Anthem approved our 13yr old daughter for a traditional (Non Omnipod) pump.
    She is extreeeeemly active (swimming, gym etc) and will not consider a pump with tubing.
    Any suggestions / advice about our 2nd appeal ...
    Anyone on the Omnipod covered by Anthem BC BS (we're in Nevada).
     
  7. ClimbfortheCure

    ClimbfortheCure New Member

    Joined:
    Apr 29, 2008
    Messages:
    1
    Hello,

    Sorry to hear that your insurance denied you and your daughter. I am a 19-year-old type 1, and I have to do all of my own self-care and insurance-medical communication. I am now happily using the Omnipod and went through a very long ordeal to get it. Here is what I learned:

    Persistence pays! I've been through state insurance and private insurance, about 4 or 5 different varieties in the 1 & 1/2 years I've been diabetic. Every time I'm on a new insurance, I retry my application.

    I was denied over and over by every insurance company, including my current one. We then appealed with a letter from my doctor stating specific "clinical" necessity. This helped, but to no avail.

    Finally, I had to get personal. I called my case manager and the medical director of my insurance company, and also the HR rep. at my father's work who handles communication with the insurance. I spoke with each of them and explained to them how difficult my diabetes maintenance was, how low my standard of living was, how emotional it was to be constantly struggling for something I ought to have the right to be on, etc. I basically put my heart on the line in front of all of them.

    This was a major factor in making a breakthrough, says my contact at Insulet corp. (maker of the Omnipod). She encouraged me to be personal and allow these people to see that they're dealing with a human being. You must appeal to them on a very personal level.

    Share your story with everyone you speak with with your insurance, and with Insulet. Make sure you are talking on the phone and not just exchanging voice messages. Chances are these people aren't evil, just by-the-book. It's up to you to show them that you're a concerned mother with a desperate need to make your daughter's life better.

    Also, do you have a personal contact at Insulet? If I may make a recommendation, ask to speak with Kobie. That is, if you're not designated someone based on geographic location. She was my contact and she was with me every single step of the way. She really cared about me and wanted to make sure I got on the "pod."

    Your personal contact at Insulet will be very instrumental in helping you from a technical standpoint. They know about the system and how it works and what to do to appeal, etc. They are your guide.

    Lastly, my insurance finally bended the rules a bit for me, undoubtedly because I brought them in the know about my life, feelings and needs. I gave them the opportunity to take hold of some responsibility for my health and well-being, and I think people are in that field because they like that. Thankfully, I was right in this case.

    My insurance decided to cover Insulet as an "in-network" benefit, rather than an "out-of-network" benefit. Were it to be covered out of network, my family would have been responsible for 30% of the costs, every 3 months. Meaning $1300 four times a year. We couldn't afford that! So my insurance, somewhere at the top of the food chain, changed their minds.

    You know, sometimes I really feel lost and alone out there, like no one cares about me or my diabetes -- not my doctor, the nurses at the hospital, my insurance, etc. But once in a while, I get thrown a bone, and it really keeps me going.

    Believe me, I've had my share of heartache. And I can only imagine what it's like for you, since you're a parent. I wish you the best of luck, and I hope you've been encouraged to keep trying!!!
     
  8. realsweety

    realsweety Approved members

    Joined:
    Mar 15, 2008
    Messages:
    228
    I sent you a pm.my daughter was also denied coverage.bc/bs ppo.We were hanging our heads in despair becouse we wanted it and so did allison.after reading that you are fighting it,I realized that we should fight for what we want also.(also pms was kicking in )I usually don't fight things,I am not much of a fighter.I usually let things go the way they are suppossed to.but this time I am not going to let a bunch of people who doesnt live our life tell us which pump is right for us.we are looking at other pumps also,just in case it doesnt go in our favor in the end.but we are going to fight for what its worth.thank you for giving me the extra kick in the behind .even though in reality you are doing it for your child.
     
  9. moco89

    moco89 Approved members

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    Try http://www.imedecs.com/. You pay $25 for a doctor to write an appeal to justify your need for a omnipod.

    The diabetes journal http://diatribe.us writes about a man who got a cgms through this appeal service even though the insurance would only pay if cgms coverage was mandated by state law. This should work for the omnipod just as effectively.

    http://www.imedecs.com/CaseReviewServices.aspx You want to elect for a Level III External review bc doctor's decision is a binding on the insurance plan.

    You can register for diatribe.us for free if your diabetic or a family member of a diabetic

    Here's the articles
    http://www.diatribe.us/issues/8/logbook.php
    http://www.diatribe.us/issues/7/logbook.php
     
    Last edited: May 10, 2008
  10. moco89

    moco89 Approved members

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  11. hrtmom3

    hrtmom3 Approved members

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    This is long, but feel free to use any of it in your appeal. Addressed to each appeal member individually. A CWD friend wrote this for me. The insurance company received this letter on a Monday late afternoon, the appeal board was to meet on Wednesday morning. I received a call on Tuesday saying the appeal was unanimously overturned and there was no need for an appeal board meeting on Wednesday. I believe it had a lot to do with this letter.

    To:

    From: Martha
    (address)

    Re: Insulin Pump and Supplies coverage appeal for Timothy******
    Member # *******
    Denial # ********


    This letter is a short explanation of exactly why an insulin pump has become a MEDICAL NECESSITY for effective diabetes treatment of my son, Timothy (age 15 years, IDDM-T1). I have also supplied huge amounts of supporting documentation separately. These will constitute the basis of continuation to the highest level of appleal if you continue to pretend that MDI (“Multiple Daily Injections”) therapy is capable of treating his condition well: It clearly isn't doing so, even with intense management. I hope that after this attempt, that you are capable of seeing and understanding the need and lack of remaining viable options for sufficient treatment of his permanent medical condition.



    1. LONG-ACTING BASAL INSULIN is having uneven action through the day.

    Back in 2005, after numerous problems using Lente, Tim was switched to a newer, longer-acting, and less “peaky” Basal insulin: Lantus. For most people, Lantus lasts about 22-26 hours, and can be used with one or two shots per day, taken at the exact same times each day. The “tail” of action at the end of the period drops off very smoothly. But for Tim, it is almost entirely gone after only 22 hours, leaving several hours “uncovered” and prone to Hyperglycemia. It takes about 4 hours for each shot to become active. And unfortunately, although Lantus is documented to have only a minor peak in effect at about +5 hours in most people, Tim suffers an extreme peak in action at approximately this time.

    In an attempt to somewhat fill in this “gap” in coverage, and reduce the dangerous peaking action which had been caused numerous severe Hypoglycemic episodes at night, we all agreed to try switching Tim's daily Lantus dose into two shots, 12 hours apart. But this did not solve the problem:We were only exchanging one BIG uncovered period, followed by one BIG period of too much insulin action, for two somewhat smaller (but still dangerous) gaps and peaks.


    The Lantus insulin should create a nearly flat level of insulin in the blood, and it does for most people. But for some, as in Tim's case, it does not. Instead, it is gradually taking approximately five hours to rise to a level of far too much effectiveness during hours +5 through +7; then works properly from about +8 hours through + 20 hours; but then declines precipitously from +20 through +22 hours. The last two hours before each shot (and of course the first four hours after the shot) are covered only by the shot from 12 hours before.

    Lantus is not working properly for Tim, although it is almost certainly working better than any other long-acting Insulin would. (Much better than the preceding Lente would be, for example.) In Tim's body, it is simply not being absorbed and released properly, leading to dramatic dips and sudden rises in this so-called “Basal” insulin's activity. That is not how MDI Basal insulin is supposed to work, and we are unable to resolve this problem. Pumping is the appropriate remedy for these ongoing extreme bG fluctuations. I should note right here that Tim's use of Humalog at meals, and for corrections, has always been very reliable and predictable.




    2. DAWN PHENOMENON in the mornings, perhaps also with Somogyi Effect.

    Tim has a strong “Dawn Phenomenon”-- an increase in bG in the morning, just before waking, which corresponds with a very sudden need for increased insulin. (This happens in non-diabetics too, but they have Pancreas functionality to provide the insulin.) This occurs before waking, and cannot be well-controlled by even a Basal insulin which works properly. The standard treatment for dawn effect is to use an insulin pump. In addition, because of the exaggerated Lantus peak which he suffers earlier in the night, he may be suffering Somogyi Effect at the same time. (High “rebound” bG levels being caused by the excessive Lantus effect at +5 thru +7 hours (i.e., earlier in the night). It is impossible to know if Somogyi plays a role (without waking him every ½ hour for testing: all we can see is an astronomical bG reading, it could be entirely due to Dawn Phenomenon. But it happens almost every day, and by the time he wakes up, it is already too late-- damage has been done, and will continue to occur for another 3 hours while a large fast-acting “correction” Dose “ramps up”.

    When a large “correction” is necessary and always happens too late, 365 mornings days a year, something else needs to be done. Pumping was invented for this problem!



    3. Using an INSULIN PUMP will almost certainly solve BOTH problems.

    As you should already know, an insulin pump is used with only “fast-acting” insulin. It will be programmed, by Tim and his Endocrinologist, to deliver appropriate “Basal” doses throughout the day-- avoiding the insulin peaks and gaps which he suffers from the Lantus shots. In addition, it will be coded to automatically increase the Basal dose each morning, from about 5 AM to about 9 AM, to handle Tim's very strong “Dawn Phenomenon”. By making a sudden increase at 5-6AM, instead of increasing too early in the night (as Lantus does), or actively “correcting” by doing a shot after waking up (which is far too LATE to prevent a major episode of Hyperglycemia each morning), Tim can have much better bG control and avoid nearly all of the problems which now occur every day, like clockwork.




    4. Conclusions.

    IDDM-T1 patients have widely varying responses to different insulin products. Unfortunately, in Tim's body, Lantus creates too strong a peak at +5 hours and too rapid a drop-off from 21-24 hours, making even a fixed daily schedule impossible to manage without severe bG variability. (And Lantus has been somewhat better than Lente was.)

    Even if some magical “new” long-acting formula WAS created, and COULD last for 24 hours without horrible peaks, Tim would still be having Dawn Phenomenon problems. The standard treatment for “Dawn Phenomenon” is pumping. Pumping is NOT experimental, Thousands and Thousands of IDDM-T1 patients have been solving their “Dawn Phenomenon” problems by pumping for years and years. No Basal insulin can be used to peak quickly enough for Dawn Effect without causing Hypoglycemia in the preceding hours (typically 3-5 AM).

    Controlling Dawn Phenomenon is critical for Tim's long-term Health: Although Tim's A1C is deceptively reduced by his frequent Hypoglycemic episodes, his time spent in severe Hyperglycemia, every morning, is clearly a big problem, which will be greatly reduced after his Dawn Effect is controlled by pumping. The Hypoglycemic episodes are themselves also a major disruption and health risk. The American Association of Clinical Endocrinologists, which is the relevant Board for this specialty, sets a target of A1C at 6.5% or lower-- but wants this done without ANY dangerous HypoGlycemic incidents. Without using a pump, it is manifestly impossible for Tim to meet these goals, and his future will be gravely compromised. (If you are not familiar with AACE guidelines for treatment of IDDM-T1, you may download them out http://www.aace.com/pub/pdf/guidelines/DMGuidelines2007.pdf. Tim, and I, and our professional team have tried very hard to make MDI work. There is not an issue with training or effort-- the MDI approach simply works very badly for Tim, and cannot be made to work properly. An insulin pump is MEDICALLY NECESSARY to avoid the excessive and damaging Hypoglycemic and HyperGlycemic episodes which he has been suffering almost every single day.

    I therefore ask for permanent approval of an insulin pump and necessary supplies to use it. If you imagine that it is not MEDICALLY NECESSARY, please provide a reasoned, written response, with full documentation, postmarked within two weeks. If you try to say that “his A1C looks fine, he doesn't need a pump”, in direct opposition to AACE treatment guidelines, you can expect future appeals.
    Thanks for your time and efforts to understand Tim's case. I sincerely hope that this letter has made the issue more clear than any previous attempts. If you choose to deny again, please provide the medical license numbers of the decision maker(s), and an appropriate legal contact's address. Although these persons might be competent and capable of making sensible decisions regarding treatment of Type-2 Diabetes, The Medical Board in his/her State might find that Remedial training in Pediatric IDDM-T1 is needed.

    Sincerely yours,
     
    Last edited: Dec 6, 2010

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