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Problems with CIGNA and pump

Discussion in 'Parents of Children with Type 1' started by CatiesDad, Feb 21, 2007.

  1. CatiesDad

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    Hello,

    Our 6 year old was dx T1 last October. Since then I have spent a lot of time researching and have found a lot of great information from all of you. Thank you.

    We have decided that the pump is the best way to go for our daughter. As she is very active we decided to go with the Omnipod. Filled out all the forms and were awaiting the final word as to what my out of pocket cost would be. To our surprise we received a letter from CIGNA indicating that the Omnipod was rejected. Spoke with the sales rep who told me that this is not unusual as Insulet (maker of Omnipod) does not have an agreement with CIGNA and is considered "out of network". An appeal letter is being drafted and will be sent to CIGNA.

    My concern is that the letter states the rejection is due to their view that Omnipod is not considered medically necessary. It seems as if they have no idea what the Omnipod is and how it works. They have lumped it in with "software or hardware additions required for downloading data to a personal computer" and/or consider Omnipod to be a "combined or integrated continuous subcutaneous insuling 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".

    Has anyone else come across this issue with CIGNA or any other insurance companies? We had gone through the pump process a couple of months ago before I had any info on the Omnipod. We initially chose Animas and that was approved within a day of submitting the paperwork.
     
  2. munsonklein

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    We had a similar experience last fall with CIGNA and Omnipod, except CIGNA never responded directly to us, even after our info was submitted to them 3 times! After 2 months of being given the run-around by both Omnipod and CIGNA, we gave up and went with Animas- we had the pump in our hands exactly 2 weeks after my first call to Animas, and my daughter has been happily using it for a month now. I still think Omnipod sounds like a great pump, but they were not upfront with us at all about their lack of a relationship with CIGNA. CIGNA has been great otherwise with covering supplies, hospitalization, etc. I don't understand why they're so closed-minded about the Omnipod, beyond the fact that insurance co's tend to dislike anything new! The people at Omnipod told us that there was a rumor going around at CIGNA that Omnipod was going to be reviewed again this month, and possibly approved- guess that hasn't happened yet. Good luck with your appeal- keep us posted on your progress.
    Cathy
     
  3. Lorraine

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    I am so disouraged about this news. We are wholeheartedly planning on pusuing the Omnipod for our 4 yr old son. My husband is currently changing jobs, and so is our insurance carrier - we will have Cigna. We won't give up easily - we are pretty committed to the Omnipod. Out-of-network coverage is better than nothing, but this seems so short-sighted. I hope news changes soon and I will let you know if we find out anything different.
     
  4. Adinsmom

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    I am in the middle of researching pumps. I called my insurance company about which pump was their preferred pump (something mentioned here). After the rep finally understood what I was looking for she read off Animas and Disentronic(???). I soon realized she was just gave me the first 2 on the list and she said she couldn't find the Omnipod. Which I knew they cover because on Insulet's website it talks about an agreement my insurance company has with Insulet.

    Anyway I had to contact another rep through secure email giving links to the product and its uses for medical necessity and their agreement with Insulet. With a little jumping through hoops they approved that pump if that is the one we choose. I think sometimes it is just getting the right person to understand and look a little further into the insurance labyrinth.

    Good Luck.
     
  5. susan

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    Our insurance also did not cover the pod...the reason our's didn't was only omnipod sells the pod and they weren't a vendor for our insurance..so we now have the minimed 522 and so far so good...
     
  6. JasonJayhawk

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    Sorry about your troubles. CIGNA does not yet recognize the Omnipod as medically-necessary.

    You'll be pleased to know that it's easier to get a "non-workhorse pump" with them -- a few years ago, you had to have some good reasons to get anything other than a Diestronic pump.

    One of the issues with Omnipod is that the pods are "disposable" -- you never own the pod. This kind of financial scheme has yet to be proven as economical. Omnipod has yet to offer their products to the states for which CIGNA provides coverage.

    If you want a pump in the next year, you'll need to go with one of the pumps that are available nationwide. (Cozmo, Animas, Minimed).

    Watch out (and perhaps avoid) the "Spirit" pump -- it is the next generation "workhorse pump" that stops working after its 4-year countdown timer is reached... it shuts off completely, as good as a doorstop.
     
  7. CatiesDad

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    Thanks for the feedback. I live in North Carolina which is covered by Omnipod. My issue is that the reason they say they are rejecting it is due to the Omnipod (in their view) as being something it is not - CGMS.

    It is one thing to reject but shouldnlt the rejection be based on fact. It is a not a CGMS.

    The reason we selected Omnipod is due to the active nature of my daughter. It's not that the other (what CIGNA referss to as standard) pumps Animas, Minimed, etc wouldn't be good choices but for my daughter we feel the best choice is the Omnipod. She is an active swimmer, plays soccer, gymnastics, etc. More importantly she has a very low threshold for pain. We tried out other insertion devices for standard pumps and she was tears each time. With Omnipod insertion she didn't even flinch - compared it to a finger prick at worst. I also tried these out and would agree with her. The other insertion devices were hard to take.

    Back to CIGNA....initially when we were first dx'ed I called CIGNA to verify my coverage. Although were not thinking to start pumping at that time I did ask if pumps were covered. The response was that pumps were covered at 100%. Problem is they didn't tell me that 100% does not mean 100%. They failed to mention that the plan only covered up to $3500 in durable medical equipment. Found out after going through with the animas pump at the end of last year (before we heard about Omnipod) when the Animas rep called to tell me what we had to pay them. Needless to say we were a bit surprised.
     
  8. munsonklein

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  9. Lorraine

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    http://www.sec.gov/Archives/edgar/data/1145197/000095013507000827/b63591s1sv1.htm#116

    Hello again. After talking to my husband, who has business experience with health insurance companies, I think I understand more why this may not yet be covered by Cigna. However, I am hopeful that it will be in not the too distant future.

    Insulet is a new company. They are in early stages of marketing their product. As such, it is currently only available on the east coast. Further, they have prioritized the insurance companies with whom they have "pitched" their product - targeted those with a larger presence on the east coast. Cigna is not one of these and therefore Cigna does not recognize it as equivalent to traditional insulin pumps. With new products like this, clinical trials and the like are presented by the company to the insurance carrier in order to explain and justify the product.

    Cigna is in the process of going public. With that, they have filed an S1 document which describes in length it's product, related benefits and plans for the future, among other things (the internet string at the top should lead to this document). Below is an excerpt from this document which identfies Insulet's need to partner with addtional insurance companies to get the Omnipod as a qualified expense in order for their business to succeed. Because of the newness of the company, they have limited resources to do this, but it is in their plans and certainly in their best interests.

    It seems it is a matter of this being a very new product and needs to go through the regular course of business. In the meantime, we are all very anxious for approval and coverage!

    The above is by no means an expert opinion. Just some thought I felt would be good to share.

    Lorraine


    Excerpt on their reimbursement strategy

    - Expand third-party payor coverage for the OmniPod System. Third-party payor reimbursement is an extremely important determinant of patient use of CSII therapy. As of December 31, 2006, we have entered into contracts establishing reimbursement for the OmniPod System with national and regional third-party payors that cover an estimated 78 million lives. To date, we have primarily focused on negotiating contracts with private insurers with a presence in the areas where we have concentrated our initial sales and marketing efforts, which has been on the East Coast region of the United States. We plan to continue to work with additional third-party payors within these areas and, as we broaden our sales and marketing focus in the remainder of the United States, to enter into further coverage contracts.
    DeleteReplyForwardSpamMove...
     
  10. CatiesDad

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    Thanks Lorraine for the information.

    Just read through the SEC registration statement and I have some new concerns about the viability of Insulet. Through my research I did know they were a new company and are trying to roll out their product to the rest of the country. What I did not know is that they are over $90 million in the red. Will Insulet be around in 2 years? I would hope to think that if they can't make it on their own that one of the larger pump producers would possibly take them over. If not I'm concerned about getting "attached" to this product then dealing with having to get used to something else. However, this may happen regardless as technology improves.
     
  11. rmccully2000

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    Omnipod + Navigator.. it's officially in the works

    Here's a quote from the SEC statement from the recent link! Thanks for posting that :)

    "For example, FDA approval of a commercially viable “closed-loop” system that combines continuous “real-time” glucose sensing or monitoring and automatic continuous subcutaneous insulin infusion in a manner that delivers appropriate amounts of insulin on a timely basis without patient direction could have a material adverse effect on our revenues and future profitability. We have an agreement with Abbott Diabetes Care, Inc., a global healthcare company that develops continuous glucose monitoring technology, to develop a product that will integrate the receiver portion of Abbott’s continuous glucose monitor, the FreeStyle Navigator, with the OmniPod System PDM. The FreeStyle Navigator is currently pending FDA approval and is not available on the market. "

    This is my dream product!! An integrated Omnipod Navigator device.

    My prediction, they will be around in two years and in ten years. They are just starting the rollout to the West Coast and are now hiring a territory manager for Illinois. They are only getting started.

    Becky,
    Mom to Mason,6 Dexcom
     
  12. Lorraine

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    Re: Debt of Insulet

    Again, I am no expert, however I have the sense that there is a lot of buzz and excitement about the unique features of the Omnipod and I truly think it is something cutting edge and will succeed. I feel so strongly about having it for my son and I can't imagine that I am alone. Because there are so many pump users out there that have to wait to replace their current pump to be covered by insurance, Omnipod is in a unique situation in that it can't tap into all it's potential customers as quickly as it might otherwise like.

    As far as Insulet's debt - I do not find that worrisome. I don't think it is unusual for a start-up company to have significant debt. In fact, to me it says that they have done things thoroughly to ensure they have a quality product. They weren't necessarily trying to skimp on their initial investment.

    I haven't reviewed any of Minimed's SEC filings, but I believe that Minimed started similarly to Insulet. It was a start-up when current pumps were being developed and was ultimately bought out by Medtronic. Look how successful and viable they are today. I would not be surprised if Insulet was bought out by Abbott - but that's complete speculation on my part.

    Further, I think Omnipod is unique in that the start up costs are much less than other pumps. To me, this provides more flexibility. As advancements are made to the disposable pods, users will be able to stay current with any improvements. If Insulet should fail, you aren't tied down to a big initial investment. Not that the approximate $1000 is nominal, but certainly a lot less than the cost of other pumps.

    I will be interested to know how your appeals go as I will be going down the same road as you in the not too distant future. My son is currently getting only 2 units a day, so a pump is not yet recommended for him. But as soon as it is, we will be strongly pursuing the Omnipod. I hope Insulet will have convinved Cigna by then.

    Kind regards,
    Lorraine
     
  13. Lorraine

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    CatiesDad,

    Hi - I was wondering if you have heard anything from your appeal with Cigna? My husband will be attending an Insulet info meeting tomorrow night and will ask about the progress with Cigna. I will let you know if there is anything to report. If you've heard anything on your end I would be interested.

    Lorraine
     
  14. Lorraine

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    Hello again. My husband attended the info meeting and Insulet confirmed that they signed a contract with Cigna within the past week. It sounds like in general they are making significant progress with insurance companies. Hopefully you will get a quick reply to your appeal.
     
  15. rickst29

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    Wow, there's hardly ANY insurance companies which LIKE Disetronic. For adults, the "Spirit" has some really leading-edge features, it's a great pump. But their support doesn't have a very good reputation.
     
  16. CatiesDad

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    thanks Lorraine,

    We are getting the runaround. Called Insulet to check on status of appeal. I was told that I would have to contact CIGNA myself and they could not do anything. Called CIGNA and was informed that the appeal was sent to the wrong PO Box and it has been sitting untouched for 3 plus weeks. I was also asked to fax them the rejection letter as they do not have a copy of this. Apprantly the review and case management functions are outsourced and handled by Intracorp. Once the "appeals" dept gets the letter of appeal signed by my Dr. it may take up to 30 days for a decision. We are losing patience. As much as we think the pod is the right choice we really need to get Catie's #'s under control. We need pump therapy soon and may have to go with another option which they have approved.
     
  17. Lorraine

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    That is discouraging news. It doesn't sound like the "approval" that Insulet mentioned. I have read elsewhere that Insulet has been very helpful with insurance companies. That is obviously not the case with Cigna. I hope the approval actually did happen and that information will quickly trickle down to the appropriate parties so that you can proceed with your pump of choice. We will be starting with Cigna next week and pushing our clinic to help us apply for the pump (although currently meeting with some resistence) shortly thereafter. Good luck. If we make any progress on our end, I'll let you know.

    Lorraine
     
  18. munsonklein

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    Your story sounds exactly like our experience with both Insulet and CIGNA. I even used the word "runaround" to describe it. If this new contract doesn't pan out, don't feel like one of the other pumps is a choice that's "2nd best". We ended up going with the Animas and are very happy with it. The tubing has not been a problem at all. Actually, we've had some trouble with bubbles in the cartridges (common for all pumps), and we've been glad for the tubing, since it allows us to see the bubbles and prime them out. You wouldn't be able to see them in the 'pod. Also, the 'pod really would have shown under my 10 year old daughter's clothing, and wouldn't have fit under some of it- her pants have gotten pretty tight over the course of the winter, and of course the stores only have shorts now! Finally, one of our friend's installed a hot tub in her backyard this year- Sarah's enjoyed being able to disconnect and soak for an hour at a time. I'm not sure how you'd handle that with the 'pod.
    Cathy
     
  19. Lorraine

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    My understanding is that bubbles are not an issue with the pod as there is no tubing. I believe to go in a hot tub you would have to remove the pod and apply a new one when you are done.
     
  20. munsonklein

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    In a conventional pump the bubbles start out in the cartridge, then flow into the tubing along with the insulin, which causes hyperglycemia, since the bubbles replace some of the insulin, so you don't get as much as you should. Basically, the tubing doesn't cause bubbles, air in the cartridge does. If I've understood the directions for the Omnipod correctly, you fill up the pod in a way that's similar to filling up the pump cartridge, so bubbles would still be a possibility, you just wouldn't be able to see them, the way you can with tubing. Maybe there's an Omnipod user out there who can tell us! The only way I can see to avoid bubbles is to have pre-filled cartridges, like you get for insulin pens. It would be 1 more advantage for the pod if bubbles truly aren't an issue, but having to replace a $30 pod every time you go in a hot tub or sauna is a definite disadvantage. My hope is that they'll eventually redesign the pods so that you can temporarily disconnect the pod from the cannula the way you do with an infusion set.
    Don't get me wrong- I think the 'pod is a great option,but it has advantages and disadvantages, just like all the others.
    Cathy
     

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