Insurance Woes


(Lori) #1

I’m new to this page, but not new to the world of Type 1. My son was diagnosed at the age of 7 and is now 14. We’ve just gotten a letter from our insurance company telling us that his new Omnipod is considered “not medically necessary”, so they won’t cover it. We now have to appeal. This is the latest in the many changes and rejections we’ve received in trying to get him the equipment and care he deserves. Any of you out there struggled with similar frustrations? I’m so tired of having to fight with our insurance company to get the things he needs to survive!


(Dennis J. Dacey, PwD) #2

Lori, I can relate to your woes. It is a shame when “bean-counters” without medical knowledge or background make life-saving, quality of life decisions instead of our medical care teams.

How is your son doing? Not just with his T1D but with life, school, activities and social? At age 14 an insulin pump should be a major step that will permit him to lead a full, productive life, giving him freedom for meal-timing changes to fit in with schooling, sports and just being a teen. Those are a few bits you could add into your appeal.

The first step is to engage his medical care team behind you, especially an endocrinologist who really knows TyoeOne [not all really do]. Have the endo write the appeal stating why, in her/his judgement that a pump IS NECESSARY; also engage an instructor / medical advisor from the Omnipod company to assist with additional data.

In retrospect, if I had the positive benefits of a pump 60 years ago I may not have developed some of my diabetes-related complications. Good Luck to you!


(joe) #3

hi @loritroll Lori,

it is the job of any insurance company to push back. first they pushed back on pumps, then lispro (fast acting human insulin) then CGM and I am sure it isn’t going to end, ever.

a good endo will write the medical necessity letter. a good pump manufacturer knows the correct words to use and how each insurance company works and will find the correct way to get a pump covered. Some companies will “favor” a certain kind of pump, a certain kind of insulin, or a certain kind of CGM over another (meaning they may only have a problem with the pod itself) , some will only push back until you do the right thing and find the correct magic words or the favored pump…

for me, the magic words were just the endo’s letter of necessity. never give up. your experience may vary.


(Lori) #4

I know we are certainly living in a blessed age to have so many amazing things available to our kids that make their lives with Type 1 easier. I can’t imagine having gone through this all those years ago. My mom’s cousin developed Type 1 in the '50s. He contacted us right away when my son was diagnosed in 2011. He was so encouraging! I’m forever grateful for those of you who came before us. You managed the disease well before pumps and CGMs and are here to tell us it’s all ok. Thank you for your thoughtful words. I appreciate them so much! God bless you as you continue to manage your health after all these years with this disease.


(mlecuona) #5

Hi Lori
I have worn a pump for over 20 years and over that time I have been in situations where I was running out of supplies and the insurance company was telling me no we dont cover
Many times I would say


(mlecuona) #6

Almost always the people working at the insurance company or the vendors dont know the proper codes or what the product is
Right now I am trying to get a CGM covered since April I finally reported the issue to the insurance commissioner who referred me to an elder medicare site who in turn followed up with my present insurance comp Preferred and they have called me 3 times since OCT 12
talking in riddles just half an hour ago I told the lady that has called 3 times I am going to my desk and writting another complain about you I have had enough of you calling me for the last 2 weeks verifying my birthday my address and telling me you have to escalate my issue you have had plenty of time to escalate I dont know where since April
It’s a shame that on top of fighting the condition every minute of our life we are treated like morons by our insurance companies when they make millions in profit


(Alison) #7

I can sympathize with the Insurance woes. I stumbled upon this forum and felt compelled to share about my one struggles with T1D as a mother of a 15 year old daughter who has been a T1D for 4.5 years. I have been in the process of getting a new pump, after she has been pumping for 4 years. Her first one is now out of warranty. I have tried to order 2 different pumps and Anthem has denied both, deeming them not medically necessary. I appealed and the appeal was denied. Even after they covered her first pump 4 years ago. I have spent countless hours on the phone with Anthem reps, appeals reps, nurses and regular people who don’t really have a clue. My biggest issue is that our doctor and insurance company have not been able to connect on a Peer to Peer phone call. It is completely out of my hands.

Just today, my daughter had a big scare with a low in the middle of the night that rebounded into a high that was escalated due to a malfunction of the pump equipment. I warned my insurance company of this very scenario and I am so frustrated with large corporations who call themselves health care providers. Luckily, my daughter and I were able to manage her situation this time and was able to get rid of keytones that registerer at 4.2 at one point. This can be an exhausting condition for both the individual with T1D and their caretakers. I know that I will continue to persevere with providing the best care possible for my child. Thanks for listening.


(Dennis J. Dacey, PwD) #8

Hi Allison @ArtsyA,
I have a pretty good idea about what you and your daughter are experiencing; I’ve been there.
My pump has a four year manufacturer’s warranty - as have my two previous pumps. Medicare [yes, I retired at age 70 after 50 years managing diabetes] will NOT consider a new pump until I have been using my current pump for five years.
If her pump malfunctioned, or you believe it did, immediately call the pump manufacturer. I suspected a malfunction with my old pump when it had been out of warranty and called Medtronic when I suspected to malfunction at about 8 PM on a Friday - by 8:15 on Saturday morning FedEx delivered a replacement pump to me.

Please don’t call insurance companies “health care providers” - that makes you sound like a politician; insurance companies are money handlers.


(Patricia) #9

we went through the same thing but our Diabetes Educator wrote a letter to the insurance company (Amerigroup) and they authorized it.


(Bill) #10

Perhaps I shouldn’t post this (Dennis, you and Joe are welcome to delete this) but the insurance companies are “chomping at the bit,” hoping they’ll be “unleashed” and allowed to raise rates/cancel coverage/and deny claims for people who have chronic medical conditions. It is revving up to be a very, very noisy and ugly fight. And it’s coming!

The only way to do anything about it is to get the attention of members of congress. Unfortunately, the representative for my area, and both senators, are blind to the needs of people who have chronic illnesses. The only way to do anything about this is for all people who have T1D to “band together,” write to representatives, call representatives, and vote the “non-supporters” out of office. It’s time to get moving on this! We have to focus our voting decisions on this single issue - healthcare. If we don’t…

Okay, I’ll hush now.

Good luck to all!

Bill