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Question about insurance and getting a pump

Discussion in 'Parents of Children with Type 1' started by kyle and ryans mom, Jul 29, 2013.

  1. kyle and ryans mom

    kyle and ryans mom Approved members

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    Animas submitted the paperwork to insurance(CHIP) last Monday. Today they are requesting 30 days of blood glucose logs. Anyone else have to do this? His numbers have been good, not too many lows or highs. Do you guys think that will affect him getting approved? Thanks for any input.
     
  2. Sarah Maddie's Mom

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    It's pretty common to request logs. The raw numbers are usually augmented with information about hypo-unawarness, perhaps the difficulty of maintaining MDI while in school etc. Your endo really should be helping to prepare the necessary documentation.
     
  3. mamattorney

    mamattorney Approved members

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    Can you find the medical policy for insulin pumps for your insurance company? That may clue you in to what they are looking for. For example, we have Blue Cross Blue Shield of Illinois. I am expecting them to ask for logs because of the policy (see bold) which states:

    An insulin infusion pump (with or without wireless communication capability) may be considered medically necessary when all of the following criteria are met:

    Documented diabetes mellitus; AND
    Completion of a comprehensive diabetic education program; AND
    Patient follows a program of multiple daily insulin injections (at least three injections per day); AND
    Frequent self-adjustments of insulin doses over the past six months prior to initiation of the insulin pump; AND
    Documented frequency of glucose self-testing an average of at least four times per day during the past month; AND
    Documentation of any of the following while on a regimen of multiple daily insulin injections:

    a. Glycosylated hemoglobin level (HbA1c)> 7.0 percent; OR

    b. Severely unstable blood glucose levels (brittle diabetes mellitus) with recurrent episodes of diabetic ketoacidosis, hypoglycemia or both, resulting in recurrent and/or prolonged hospitalization; OR

    c. History of recurring hypoglycemia or severe glycemic excursions; OR

    d. Wide fluctuations in blood glucose before mealtime; OR

    e. Fasting blood glucose levels are much higher on awakening in the morning (?dawn phenomenon?) with fasting blood sugars frequently exceeding 200 mg/dl; OR

    f. The patient has been on an external insulin infusion pump. The pump is no longer functional and not under warranty, or is greater than four (4) years old.
     
  4. Mish

    Mish Approved members

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    I'm generally a very honest person but I would toss in some lows at night in random places.... (unless they're asking for downloaded logs, which I doubt because not everyone has that capability, and if they are indicate that you only have paper handwritten logs)
     
  5. virgo39

    virgo39 Approved members

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    If it were me, I would think twice about submitting inaccurate or falsified records to an insurance company in an effort to secure coverage. Independent of whether it is right or wrong to do (and one could certainly make an argument that such records should not be necessary to determine whether one's insurance should cover a medical device), depending on the law of the applicable state, the consequences could potentially be quite drastic.
     
  6. kyle and ryans mom

    kyle and ryans mom Approved members

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    I actually faxed in his logs as soon as I got the call from animas that my insurance was requesting them, before even starting this thread. Then I started worrying if his numbers were to good to get approved. His A1c has been in the 6's for the last two years. Our insurance is like CHIP, but called Delaware healthy children's program. I faxed in his blood sugars as they were and I will just wait and see.
     
  7. mom24grlz

    mom24grlz Approved members

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    i had to send Animas Ashleigh's BS logs. I forget how many days/weeks they wanted. Then animas sent them to our insurance company. I'd hope having good bs wouldn't deter them from approving a pump. Ashleigh had A1Cs in the 6% range on MDI and we were approved.
     
  8. mamamccoy87

    mamamccoy87 Approved members

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    We had to send in logs - like mamattorney said, its more to show you test sugars more than 4 times a day and its warranted. Insulin pumps are pretty much the standard of care so I think it shouldnt be an issue. Not thinking they are judging the numbers - Lord knows they fluctuate pretty much on a day to day basis:cwds:
     
  9. quiltinmom

    quiltinmom Approved members

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    I would not do that. I think it is unlikely you will be denied a pump because he has good numbers.
     
  10. Sarah Maddie's Mom

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    Until meters are spot on accurate I agree with ^^. There's no point in treating these numbers, particularly this arbitrary 30 day prior to submission as the Holy Grail. I think the submission of a log should reflect the actuality of D, which we all know to be unpredictable.
     
  11. kyle and ryans mom

    kyle and ryans mom Approved members

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    Animas called me today.....we got approved and the Ping will be here tomorrow.
    Yeah!!!!! I guess I was worrying for nothing.
     
  12. obtainedmist

    obtainedmist Approved members

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    That's wonderful! Happy pumping! :)

    P.S. Worrying is what we mother's do BEST! :)
     
  13. mamattorney

    mamattorney Approved members

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    Great news!
     
  14. Lizzie's Mom

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    This is very good advice.

    We have state insurance for our TID, and needed a Prior Authorization for the pump and for CGMS. Both PA's required 60 days worth of logs.

    I've found over the past four years that if I give the insurance company what they need, they give us what we need.

    Getting clarification from the Prior Authorization dept. with your insurance company might be helpful; they can help to show you where to look up policy online and/or interpret that information.

    Logs are always a good idea; when our insurance's preferred drug list did not include Novolog and she was switched to Humalog, we noticed that she had rashes at the infusion site and her numbers were terrible. I had some Novolog still in the fridge, so we'd do a week of Humalog, a week of Novolog (for two months), and documented the numbers. Her numbers were MUCH better and much more steady on Novolog. I gave our insurance provider the info they needed and we got the PA for the insulin that worked best for our daughter. They like to avoid trips to the ER for DKA :cool:. The best insulin fit is cheaper in the long run for them. The following year Novolog was back on the preferred list :).
     

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