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Pump Denied Again

Discussion in 'Parents of Children with Type 1' started by MommaKat, Feb 8, 2012.

  1. MommaKat

    MommaKat Approved members

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    I am shocked, my stomach is in knots, and I feel so done with the state of Colorado right now. The Medtronic insurance person never called, so I phoned her and could tell she really didn't want to have the conversation we were about to have. They've never, to her knowledge, had a pump denied by Medicaid before. Medicaid said it's not medically necessary because dd is well controlled on MDI. Really? Could they please send someone over to show me where in her logs we see the picture of 'well controlled'?

    So, I did what I always do when I'm extremely emotional - I wrote. I have now emailed it to every division leader for Colorado Department of Public Health, state Medicaid program, EPSDT, and the Health Care unit for Children with Special / Chronic Health Care needs as well as the governor. After that, I posted it on my blog as an open letter, and shared it to both facebook and google+ (my name is linked to face book and the blog link is in my sig if you want to read it, but it's long.)

    Not that it will have an effect on anything, but I'm so tired of everything we've gone through since diagnosis, and can't conceive of just sitting by and letting life happen anymore. I am fighting this decision. Period.
     
  2. zoomom456

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    Oh Kirsten,

    The only thing I can think of to say is THAT SUCKS!!!

    How is Nik?
     
  3. MomofSweetOne

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    Kirsten, I am so sorry. You've been fighting so much for so long and now this. If they had to live with what Niko is, they'd approve it instantly. That many shots a day is hard. I know; we did it. I don't understand their decision at all.

    Your letter is excellent. Have you also sent it to your state and national representatives? Anyone and everyone who might be in a position to make some waves?

    Tell Niko my daughter was in tears when I told her; she's not alone even if it feels that way.
     
  4. Darryl

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    Sorry to hear that. Keep fighting, and good luck.
     
  5. Cookie Monster

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    I don't fully understand how things work in the US (if work is the right word?) but you have to fight this.

    You have two things in your favour: from your blog you are clearly a well-educated, intelligent woman with a working knowledge of the medical field; and you write well.

    Use those qualities to their maximum impact. Take it as far as you need to.
     
  6. Lenoremm

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    It is horrible and I am sorry you have to fight this along with everything else. You are obviously well equipped to fight the good fight and be the advocate your dear daughter needs now. Keep at it!
     
  7. Rcj176

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    Go Momma!! Frustrating isn't a word that even comes close to how hard it is to care for a child with diabetes.
     
  8. Beach bum

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    Frustrating. What are you supposed to do, stop being so good at managing your child's diabetes so that her numbers are all over the map so that she can then get a pump? I swear, these pencil pushers have no clue. Do they not realize that by having this it will only help your child continue on this road of successful management?
    The sad thing is is that there are probably other kids in your boat (well cared for, good numbers etc) that have gotten a pump without issue.

    Can your endo assist you on this at all?
    Call the media, call your local papers.

    I'm so mad for you!

    Oops, just read your blog and the struggle with the numbers and illness. YIKES. Obviously, there are a bunch of untrained monkeys (sorry monkeys I'm insulting your species) reviewing medical forms.
     
    Last edited: Feb 9, 2012
  9. Tracy1918

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    That is just wrong. You are such a good mom for fighting back.
     
  10. Melissata

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    Kirstin,
    I just wanted to tell you that I know that you WILL win this fight for your daughter, hopefully soon. There is simply no reason that you were denied a pump. I am not surprised about the CGM though. It is Medicare/Medicaid practices that are causing other insurance companies to deny CGM coverage. My daughter cannot possibly live outside of our home until we can get Medicaid coverage for CGM. We are lucky enough to have my husband's employer agree to keep her on his policy because of her disability, and if she moved away from us, that coverage would be gone and she would have only Medicaid.

    I do know that Medicare has paid for CGM's for some, so am hopeful that more and more people will fight for Medicaid to pay for them on a case by case basis. I had to fight Blue Cross of Michigan in order to keep her on her Dexcom when we had to change insurances. I also had to fight for her to be able to keep her Omnipod. Since Medicaid and Medicare don't cover it, BCBS was not going to either, even though she already had it.
     
  11. Mommy For Life

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    What a bunch of BS! I am so sorry you are dealing with this! I don't know you personally, but from reading your posts and blog, I am positive the folks that get in the way of your sweet girl getting a pump, wont know what hit them! ;) You are a strong and confident MamaKat! I will be sending prayers that this goes your way fast and without anymore bumps in the road! Go get them MamaKat!! :cwds:
     
  12. MommaKat

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    Oh my, but this process requires amazing patience. That said, I've learned so much today, and as dd points out the axiom The pen is mightier than the sword exists for a reason.

    The truly mind boggling things I've heard
    The medtronic insurance person we're dealing with said Medicaid won't give them a detailed rationale for denial, and that there is no appeal process.

    The insurance person assigned to pump orders and insurance plan issues at Barbara Davis asked me if there is an appeal process. She simply kept saying they've never had this happen before and doesn't know what to do. (I don't buy that, but it doesn't matter.)

    The center sent a certificate of medical necessity and 32 pages of logs and documentation from... last March and June. Really?!? You took records from one and three months post diagnosis, when my child's insulin needs tanked due to swimming and honeymooning and used those to document medical necessity?

    There is an appeals process - I request in writing a hearing with the Office of Administrative Courts, and a judge who typically presides over worker's comp cases makes a ruling. Evidence may not be more than 10 pages in length and the soonest we can get a hearing is April or May.

    The slightly more promising News

    Medtronic simply gets a narrative from the doc and resubmits a brand new claim that would be reviewed and decided on within two weeks of submission. We'll go that route.

    There is a reason listed on the denial which simply states patient appears well controlled on insulin injections. We have LOTS of night time lows even in those records, and many, many nights where she had to go to bed at 250 in order to avoid dropping too far. (Not what I consider well controlled! At least I can ask what they actually read / paid attention to.)

    I found two research articles written about the need for good control prior to pump start that the insurance industry used to deny pump coverage until the children had been on MDI for a year - Golden.

    I found another research article that clearly delineates A1C levels with negative health outcomes (a chart was posted here last fall I think). Again, according to this chart she hits a level where diabetes begins to exact a toll if allowed to remain at that level. No, it's not terrible, but it's false to say it's well controlled and poses no risk to her future health.

    I pulled together records on her functional heart murmur / mitral regurgitation, vision concerns and damage to retina from a different condition, and her renal history (chronic infection with glomerular damage, spilling, etc.) and the rationale for tighter control given this medical history.

    So I am now composing a new letter to send to the county comissioners (I realized the medical board reviewing prior auth requests is answerable to the county comissioners), my local representatives, and the Barbara Davis Center to include in her chart.

    I swear, she will have a pump by this spring.
     
  13. Sarah Maddie's Mom

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    Well, a log is a log book and books can be fiction or non-fiction.:rolleyes:

    FWIW our first two submissions were declined by our health insurance. More letter, more logs and they did an about face.
     
  14. MrsBadshoe

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    Ours had quite a bit of fiction....:rolleyes:
     
  15. lilwitte

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    That is exactly how I got my CGM covered by insurance. I had to prove that i was having X lows below 50 a week but I we were already paying out of pocket for sensors so I was rarely having lows below 50. The use of my fictional log helped get my sensors covered...

    I would think that using her blood sugars from the past few weeks from her being sick and being constantly high then abruptly dropping low would be sufficient evidence of "uncontrolled" diabetes for the insurance company.
     
  16. MommaKat

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    Guess I'm dense from lack of sleep... her log is downloaded directly from the meter, so the only fiction might be when she eats, what she eats, or how much insulin she gets. Not sure why I wouldn't be one hundred percent accurate with that, or how anyone making insurance determination for PARs could read what's been submitted as a work of fiction. :confused:

    This is our second denial, and I realize that many people go through that. I'm still frustrated - but it's about the denial of something for which she meets medical criteria. I'm not moaning about denial of the CGM, I expected that, but also understand that there's still conflicting evidence and research about the benefits for children. I certainly have my own personal and professional beliefs, colored by having a child with type 1, about the clear benefits of cgm for kids, but I accept that denial as understandable within the framework of our medical system. The pump denial, not so much.

    I've heard from several people at the state level, and while we don't have a favorable review of our prior auth request (yet), publishing an open letter has had a clear effect at at least getting some attention on the denial of test strips and pen needles. A definite step in the right direction. The last person i spoke with (head of DME for CO Medicaid) is requesting of review of the decision and asked me to have her endo submit a new narrative. Hopefully we'll have more positive news on pumping next Monday!! (and, I'm sending the BGs from the last three weeks documenting those swings you mentioned lilwitte - thanks for the suggestion!)
     
  17. KatieSue

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    I think people meant they had submitted written logs and the numbers may have been fudged a bit for dramatic affect.
     
  18. Sarah Maddie's Mom

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    You clearly have it all worked out. :rolleyes:
     
  19. MommaKat

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    Got it, lack of sleep does not promote clear thinking. :rolleyes: If we could submit hand written logs I might have been tempted to be dramatic. ;) Sadly, only logs downloaded from meter are accepted with the PARs and requested / submitted to pharmacy in order to get 300 test strips a month. We were down to 200 until we agreed to do that. Pharmacist and I both roll eyes and smile during the hand off - she's annoyed she has to collect them, I am for having to submit them, but whatever - it gets dd what she needs.
     
  20. hawkeyegirl

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    Well, there are ways to mess with meter readings, too. For instance, if one's hands are wet when taking a reading, the resulting number will be much lower than it should be. Quite a bit lower, in fact. LO, even. ;)
     

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