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Re: [IP] Coverage



> The national BC/BS changed their DME as far as pump coverage goes
> effective April 2003.  They will no longer automatically cover type 2s
> for pumps.  In fact, they will reject the claim out of hand.  Your
> doctor will have to file an appeal and better have a very good reason
> to justify the pump.  I had gotten an IR-1000 before they had changed
> the rules.  My endo decided that he felt that I needed the finer and
> lower basal dosage of the IR-1200.  Anthem BC/BS rejected it initially
> because I'm type 2 and said that because of their change of policy

Ooooohh... this is the crap they pulled 10 years ago. The old "policy" 
routine. Well, fortunately there is a very easy way around that. One 
question fixes it and opens the door for a breach of contract lawsuit 
which they DO NOT WANT TO LOSE. In California, insurance companies
MUST provide diabetes supplies, including insulin pumps. The contract of 
insurance includes this language. 

The question: Where in my written contract of insurance does it say that 
an insulin pump is not covered. (large PERIOD). If it's not there, they 
can not deny coverage if the physician has prescribed a pump and written 
a letter of medical necessity. To do so is in violation of both state 
law, and the contract of insurance (breech!).

The people you speak to will try to divert you to other arguments by 
asking for all sorts of things (which are not required). Keep hammering 
on the same question and escalating as high as necessary. When they 
figure out that you are serious and represent a threat in the form of a 
lawsuit "they do not want to loose" they will cave in and provide you 
with the services spelled out in the contract of insurance. To wit... a 
pump.

Michael


> they would not grant the pump.  My endo had to put in an appeal and it
> involved a lot on his part to medically justify the IR-1200.  So just
> a word of warning.  And Anthem just merged today with their California
> counterpart making them the largest health insurer in the US.  So
> beware, because in the way of cutting costs for health care, pumps are
> big ticket items and when companies look at ways to cut the health
> insurance costs that is one of the first things that will be cut from
> coverage.
> 
> Bruce
> 
> 
> On Wed, 1 Dec 2004 19:00:04 EST, email @ redacted <email @ redacted> wrote:
> > 
> > 
> > I
> > 
> > It depends on what type of plan you have with BC/BS, but overall BC/BS pays
 > > for all brands of pump and does not require jumping through numerous
hurdles.
> > Good luck!
> > 
> > 
> > .
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> > contact: HELP@insulin-pumpers.org
> .
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