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Punished for good behavior...A1C

Discussion in 'Parents of Children with Type 1' started by quiltinmom, Apr 5, 2011.

  1. quiltinmom

    quiltinmom Approved members

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    The good news is that DS's A1C was SUPER! 6.2!!!!!!!! I thought it would be somewhere in the 6.7 range.

    So, the bad news is the dr. said it makes it a lot harder to get a pump. :( He said there's "about a 30% chance" the insurance will approve it with such a good A1C. Dr. said he would appeal, but didn't sound too hopeful.

    DS is getting more and more anxious about pumping...I hate to disappoint him.

    My question is, is there anything I can do (paying out of pocket is not possible) or are we at the mercy of "the system?"

    Thanks!
     
  2. McKenna'smom

    McKenna'smom Approved members

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    I say go ahead and try to get it. It may depend on your insurance company on whether or not they will deny it. I requested one through Animas and they got the doctor's script and handled the insurance for me. My DD had a 6.something A1C at that point and she got the pump with no problem. I don't think getting or not getting the pump approved should be based solely on an A1C.
     
  3. caspi

    caspi Approved members

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    I don't understand insurance company logic. The pump is just another form of insulin delivery. Why they would reject it is beyond me. Good luck and hopefully there won't be any issues.
     
  4. 3kidlets

    3kidlets Approved members

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    Our insurance company didn't even ask for an A1C in the paperwork that the dr. had to fill out for the pump.
     
  5. obtainedmist

    obtainedmist Approved members

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    I would think that the doctor doesn't make the determination about pumping...the insurance company does. As long as he writes a letter stating medical necessity, I would think it could fly. There is more to the story than the A1c. He could speak to avoiding burn-out and maybe some psychological points that would make the pump a better match for your son. Some insurance companies don't make you jump through the hoops. You can always submit the request and even if you get denied (which we did initially), you can appeal the decision. I hope you get more good advice from others who have gone to the pump with good A1c's. It just doesn't seem fair and I firmly believe that there will be a way for you to get approved! Fingers crossed!
     
  6. caspi

    caspi Approved members

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    Or perhaps the doctor was confusing the pump with a cgms. :confused: I can see an insurance company perhaps balking at a cgms with that A1C number. Who knows with insurance companies! :rolleyes:
     
  7. Flutterby

    Flutterby Approved members

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    There should be no reason why you can't get a pump with a good A1c. Pumping shouldn't be just for 'better control', its simply a different way of delievering insulin. If he wants to pump, then he should be able to pump. With that low A1c you could always say its from to many undected lows because you can't accurately dose him with syringes. Definitely go for it and if it comes to appealing there are ways around it... I don't hear of to many people that are denied a pump. Most states have mandates of the insurance companies HAVING to cover pumps.
     
  8. frizzyrazzy

    frizzyrazzy Approved members

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    I guess that is such an outdated way of thinking - that a pump is used only for people who have REALLY bad control. Maybe that was once, but it isn't now. We see here people on pumps with horrid a1c, and people with MDI with great a1c.

    sure, pumps can be a tool to help people get better control, but they can also just simply be an alternate delivery method that one picks due to preference.

    Why the insurance companies put up these roadblocks is beyond me.
     
  9. hawkeyegirl

    hawkeyegirl Approved members

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    I guess it's possible that it might take a little more work on your part, but I wouldn't worry about it at his point. Our a1C was in the 6s and we got a pump (and CGM) with no problem.

    Submit the paperwork and see what happens.
     
  10. jules12

    jules12 Approved members

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    I say go for it! You never know until you try. If they deny it and you really want it - appeal appeal appeal!!!!!!
     
  11. denise3099

    denise3099 Approved members

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    Um, cuz they're paying for it?

    You can't go in with the arguement that it's just another way of getting insulin--if that were true then they'd just say, Well then fine, you can use syringes! Which are way cheaper than the 6-7K you want them to fork over. They pay under the argument that the pump is "better." I could see any company saying, look we are a buisness and pay to keep you healthy, but if you are doing well on mdi, and many many ppl are, then we shouldn't need to pay 6 grand for a pump.

    I don't think that's right, and would fight it to the end, but you can see where they are coming from. Apply. If they reject you, you make a case for "needing" it based on maybe highs and lows, or whatever else might apply to you. You might even be able to argue that the sacrifices in your case and for your child make having a pump a quality of life issue. But don't borrow trouble--you might just get approved no questions asked. :D
     
  12. Stacey Nagel

    Stacey Nagel Approved members

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    cant the dr say the A1C went down because of too many lows?
     
  13. timkris724

    timkris724 Approved members

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    What about the argument(even if you don't agree) that a pump is easier in a school situation. It has less sharps, less user error for teachers ect.. I am sure their are plenty of arguments to give an insurance company other than A1C.
     
  14. gerry speirs

    gerry speirs Approved members

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    Must depend on the Ins Co, We had A1c's in the 6's and still got it no problem.
     
  15. timkris724

    timkris724 Approved members

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    Oh that is a good point, I mean 6.2 is almost too good isn't it?
     
  16. vettechmomof2

    vettechmomof2 Approved members

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    Our original insurance company had it listed that an A1C of under 8 would need special consideration for a pump.
    Since we were already on it for this insurance company I never actually looked into it.
    So, yes insurance companies can and do make statements about it at times. Your doctor should be able to fill out a form stating his reasoning about it being medically necessary if your insurance company has any issue with it at all. Plus your insurance company should be able to send you a copy of their requirements for getting approval for the pump.
    Good luck,
    Allene
     
  17. GreenJenny

    GreenJenny Approved members

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    I would encourage you to give it a shot. My daughter got her pump no questions asked 1 year after dx. Her A1C at dx was 8.4 and had been under 6.6% for the entire year leading up to the pump. We have blue care network for insurance.
     
  18. mom24grlz

    mom24grlz Approved members

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    i think you should try. Ashleigh got a pump and her AIC was 6.0% when we started the paperwork to get it. If the insurance tries to deny it, see if your doctor will write a letter of necessity.
     
  19. nanhsot

    nanhsot Approved members

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    Your Drs. thoughts are not specific to YOUR insurance company. Find out exactly what your insurance company requires, they will have a specific listing of requirements for approving an insulin pump. Ours required a certain level of c-peptides and antibodies specific to Type 1. We had to do some juggling because my son's initial C-peptides were too good but eventually the level of auto-antibodies got the approval.

    Our insurance didn't even look at A1C.

    Apply. Don't let the MD opinion hold you back. Every insurance company is different and it's a bit limiting to paint them all with one brush.
     
  20. SarahKelly

    SarahKelly Approved members

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    if you can show that he had several lows in a week than the insurance company will be more for it...sad, huh? But that is what got ours approved quickly - a log of several days showing the ups and downs of type 1 (which is normal!) but from an insurance perspective it warrants a pump...silly, but is what worked.
     

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