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Re: [IP] My first HbA1C since going on th epump
> The insurance company says they will consider it if my doctor
> writess that it is a medical necessity. I'm not sure what that
> means in my case.
The really don't want to see a letter of medical necessity since then
the MUST pay for the pump. So.... get a sample letter from your pump
company and give it to your doc to help him draft one for you.
The bad news is that your situation is pretty common. The good news is
that in 2 years of helping with these situations, I've yet to see one
where coverage is not eventually provided. It is just and incredible
hassle to jump through all the hoops. You must be prepared to be a
permanent pain in the side of the insurance company.
First -> get WRITTEN denial so you really have something to beat them
up with. If they balk, tell them plainly that you plan to appeal and
need the letter of denial.
Most insurance policys are written in a manner that says all normal
medical expenses are covered unless experimental or specifically
excluded. Since you are unable to negotiate the terms of the policy
and must accept what they provide for policy language, the courts have
taken a strict interpretation of the language to mean that if the
insurance company forgot to mention something, they are obligated to
provide it. Bottom line, pumps and supplies are covered unless there
is specific language to the contrary. You may have to appeal, you may
have to involve the insurance commissioners office or state department
of labor in the case of a union sponsored medical plan, but DON'T give
up, don't take no for an answer. If prescription diabetes supplies of
any kind are covered, then all the pump supplies are probably covered
as well as described above.
There must be specific policy language written in your policy as the
basis for denial. Insulin Pumps and their supplies are conventional
therapy for diabetes that can be prescribed by any physician.
All that should be required for coverage is a prescription from your
physician and a letter of medical necessity The insurance company can
not contravene a doctors orders for treatment unless those orders are
patently unreasonable and inappropriate.
Use the wooden leg story and stand up for your rights. A letter of
medical necessity "should" be all that is required. That doesn't mean
it will work, but you must address the legal issues of the the policy
language, age discrimination, etc.....
Good hbA1c's are an indication of a patient that works hard at
control and is a GOOD candidate for a pump, not the other way around.
They need to understand that (they do, but tell them again).
Good control improves with the use of a pump and will reduce
overall long term health problems, costs, etc... see the hbA1c
improvements on the about page of the web site.
Use the DCCT information (see the LINKS page). Your son's hbA1c's are
still not good enough if you want to do a comparison (which is BS of
course but useful non-the-less). The average hbA1c's for DCCT
participants was 7.2 as I recall. The majority of participants in the
DCCT switched to insulin pumps because tight control was easier to
A drop from 7.9 to the 6's will mean a 50% reduction in the
probability of complications of ALL kinds for you. To the
insurance company this is BIG $$.
Address the quality of life issues, sick days, etc...
point out the rigid schedule, eating when not hungry, not eating when
hungry, problems with adolescence, etc... Mention the cost of ER
visits for low blood sugar epsiodes caused by long term insulins. Make
sure you GO to the ER for these problems. Might as well sock it to
'em. I know it is not convenient to do this, but it may be necessary
to motivate the insurance company.
Consider talking to your attorney and the insurance commissioners
office about the insurance company not living up to it's contractual
obligations to provide medical care. Insulin pumps have been around
for over 20 years. They standard treatment for diabetes care and
represent the "gold standard" for such treatment. Is there a
ligitimate reason for refusal of care that is contractually based?
At some point in time after you have been reasonably polite, start the
appeals process. Even if this process is denied, continue at that
point to contact the medical director for the insurance company and
re-start the process. You must use the "wooden leg" story, all the
economic arguments on reduced complications, cite the results from the
DCCT, etc... They'll eventually cave in. Keep up the faith, attack,
BTW, the wooden leg story is: Postulate that you lose your leg in an
accident. You contact your insurance company to arrange for coverage
of a prosthetic leg which is covered under durable medical equipment
and they deny coverage and mail you a wooden peg leg. Their argument
is that "you can get by with that". Question? Would you accept that
based on the policy language and your payment to them? Of course not!
The policy does not say they are required to provide you with a modern
prosthetic appliance, however, it IS common medical practice. There is
no difference with an Insulin Pump.
Many of the list members have faced similar problems and there MAY
actually be someone who has the same insurance carrier. This has
occured a couple of times already and proves most embarassing to the
insurance company when someone they have denied can point to another
policy holder that has been granted coverage. Even if this is not the
case, you will find the support helpful. There will be many more
ideas than the ones I have presented. Don't give up, you will win!
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