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Pump denied

Discussion in 'Parents of Children with Type 1' started by hrtmom3, Nov 8, 2007.

  1. hrtmom3

    hrtmom3 Approved members

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    Well Tim has had d for three years now and two of those years the endo has been suggesting the pump. Tim has wanted nothing to do with it up until about a month ago. For the last few weeks he has been asking how long will it take to get it. He and I both have been nervous, but anxious about him starting the pump. Today we got the call from Minimed telling us the insurance denied the pump and the reason for it was that his A1C's have not been continually lower than what they feel for it to be medically necessary to wear the pump. I feel like we are being punished for doing our best to try to control his D. His last was 6.? Good A1C, but those were the few months he was having trouble with the Lantus and experiencing 40 range lows due to the peaks the Lantus is having. He is still experiencing the peaks, although not as low, because I have been putting off upping his lantus to where it should be to avoid those 40 lows assuming the pump would be coming and things would get better. The next step is for the endo to send in an appeal.
    I'm tired, frustrated with D right now and WANT that pump for my boy.
     
  2. akrickard

    akrickard Approved members

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    I heard at our support group meeting a couple of months ago that a lot of insurance companies initially deny them. Just be sure to call, find out what the appeal process is, and follow through with it. I know it's a hassle and wears you down, but I bet he'll win out in the end.
     
  3. Mama Belle

    Mama Belle Approved members

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    What insurance do you have? Is this just for the pump or for the pump CGMS combo by Minimed? Definitely submit an appeal. That is ridiculous that they would punish him for having good A1cs.
     
  4. momtojess

    momtojess Approved members

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    When we got the pump, our endo and animas handled it all. The endo had to write a letter stating that while the a1c is good, the blood sugar are not stable, etc etc.

    Call teh end and minimed and let them handle it. I havent heard of them denying pumps much anymore
     
  5. Ella's mom

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    OH Martha so bummed hearing Tim's pump was denied. Hoping the appeal goes quickly and that Tim won't lose intrest in the idea of pumping.

    Hugs to you and keep up the good work:cwds:
     
  6. Hollyb

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    I hate that double whammy with a pump. If your sugars are out of control, they say you aren't "stable" enough for a pump. If you work really hard and your A1c is good, you don't "need" it badly enough. Talk about a Catch 22.

    Don't give up. Pumps are great for kids this age.
     
  7. Sarah Maddie's Mom

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    We were denied 2x before Health Net agreed to cover Maddie's pump. Just have your Dr re-submit. Hang in there!
     
  8. lilituc

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    Are you in Washington state? Because I think that is against state law here.
     
  9. CDoyle1013

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    appeal, appeal, appeal (find out the exact reason you were denied first). I always tell them that as an attorney, I have all the time in the world to challenge them, including court litigation. I am happy to say that I have had every appeal reversed. They want to deter you and have you give in and go away.
     
  10. naomi petty

    naomi petty New Member

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    Understand

    I feel for you and hope you can get a pump soon! My boy has been diabetic for 1 year and I totally understand about the lows and this week highs!! We are looking into the Omnipod. There is a web site to research it for yourself . It may be something they will be willing to help you with. Everything I have read about it is very positive . Take care
     
  11. thebestnest5

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    It sounds like the insurance game (I heard this from someone who works in insurance)...They deny first and most people will just give up.

    I agree, appeal, appeal, appeal. Let them know you won't give up.

    Find every resource you can on the benefits of pumping for diabetics...enlist your Endo's office for help.

    Sorry, that you are going through this. :cwds:
     
  12. TheFormerLantusFiend

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    They want below 6%?!
     
  13. hrtmom3

    hrtmom3 Approved members

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    Thanks all for the replies and support.

    Yes we are in the state of Washington and Tim is on state insurance (Community Health). We had just put in the application for the pump not the CGMS.
    Tim and I had a good talk tonight about his pump. After I had told him that I was so sad for him that this happened, He, of course, stepped up to the plate and reminded me that he has learned that sometimes you just need to go with the flow. He said he would get his pump even though it would take a bit longer. (then added even if he had to steal it). Of course he was just trying to make me laugh.
    Tomorrow I will start to go with the flow....of starting the appeal. Since the endo downloads Tim's meter on each visit and these downloads I believe only show a week or two all that has been happening with his numbers are not recorded anywhere except in my head. So Tomorrow I will need to start writing everything down just in case and oh how I hate righting it all down. Ok, I have to do my best to help Tim have good bs, and that is what I am always hoping for but this might sound weird but I am nervous that he is going to have great numbers for the next few weeks and then they will have a better argument on their side.
    I have already left a message at endo office that he needs to appeal, tomorrow I will start to research and put together a letter,
    and we have an appointment next Tuesday.
     
  14. Brandon B

    Brandon B Approved members

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    Our ins denied at first and they told us they needed more proof of the lows- Hi we gave them 10 pages then they approved it. Also the person who denied it was an Ins auditor she had no real clue what a pump was, The Dr told me this by her letter to the Dr dont give up.
     
  15. miss_behave

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    Get your endo to write a letter of medical necessity
     
  16. Flutterby

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    most states have laws that require medical insurance to cover diabetes supplies and an insulin pump is considererd standard form of insulin delievery now. if they are still dening.. bring up the laws.. not sure what state you are in.. but I believe MOST states have this law..

    with a form a medical necessity from your dr. they can't deny it either.. if its part of standard medicine.. they can't deny something that is medically necessary..
     
  17. Mom2rh

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    Our son's A1C has been very low since dx. The endo wrote a very convincing letter about our fears of undetected lows...etc. and we were approved.

    I hope the endo can write a very convincing letter. Appeal appeal appeal. {{{hugs}}}
     
  18. Flutterby

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    if you have state insurance they have to cover it.. they are playing a game..

    ugh.. I just found this http://www.ncsl.org/programs/health/diabetes.htm
    Washington is ONE of THREE states that has a law stating it HAS to OFFER it but not cover it.. how sneaky and wrong is that.. I"d keep appealing..
     
  19. Charmed7

    Charmed7 Approved members

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    My endo, and the rep from the pump company took care of everything. The endo wrote up the medical necessity, and the pump company asked me for 3-4 weeks of numbers. I just ran through the meter wrote date time and number. I didn't have to explain what he ate or how we treated high/low or anything. It didn't take me long with my hubby calling it out and me writing it down. Then I just typed it into a spread sheet and faxed it over. And I'm on state insurance too. Use your resources. Call the pump company and your endo and ask them what they can do next. They do this every day and know how to push the right buttons for insurance companies. Don't get too frustrated. Just think of it as a process. Good luck.

    Charmed
     
  20. Abby-Dabby-Doo

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    Martha~
    I'm sorry! Keep fighting, I agree with the others, appeal, appeal, and appeal.
    Definitely use your resources that have dealt with this before, which would be the Endo and Pump Rep. Don't try and do this alone, USE your resources to do your battles.

    My other advice is to look into the meter your using and software for it. MOST meter companies make a cord to plug into your computer to download the numbers so you don't have to write everything down. That function will come in handy when your pumping anyway to get information to your Endo's office/CDE. I think it would be worth the money down the road.
     

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