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Re: [IP] Now I'm Worried

Paul Whitaker wrote:

>My AC1 results were discussed. My most recent, the result I received last
>week was 5.9, that's a big difference from 12.2 back in January when I was
>dx'd. She said it would be best to tell the insurance company the high
>result as they may not approve a pump because it's obvious, (at least for
>now), that I can control my bg's with exercise, change in diet and multiple
>injections of NPH and Humalog.

I was also able to maintain fairly good A1Cs (7.2 or so - not far above lab
normal) prior to pump initiation in 1996. I did this through exercise, diet
and an ample supply of good luck. I never went the MDI route. I was on a
regimen of two shots a day, sometimes adding a third at bed to adjust for
high BGs.

I considered my pump request to be a "quality of life issue" and my
internist fully supported me in this argument. I had little control over my
work schedule, working anywhere from 40 to 70+ hours per week, varied lunch
times and fluctuating activity levels. Reliance on "traditional" methods of
control, such as scheduled meal times, strict insulin doses simply didn't
work. My numerous nocturnal hypos during my DM career were evidence that I
needed something different.

Despite all the documentation presented by the doc and the pump rep the
insurance company balked at approval. I took the initiative of calling the
insurer, warning them to "clear the decks" and get ready, because I was
faxing them 15 years' worth of BG and exercise logs. Apparently, the threat
worked, because they approved the pump a couple hours later.

That was my experience.

Another way to view your results since January is that you've made dramatic
progress - at what cost? You are possibly sacrificing flexibility, forcing
yourself to stick to a schedule that is unrealistic and has proven in many
cases to be less than an ideal treatment regimen. I think this is one of
the main reasons we are seeing so many newly DXed folks (less than one year
with diabetes) getting approval for the pump. Many of them had the same
dramatic A1c changes that you experienced. That's the result of tight
control and paying attention to the details. The quality of life issue is
extremely important.


>So, can the insurance company override my Endo? Also, if I tell them the
>higher AC1 and then find out later by some means that I had withheld a lower
>number from them, can they demand the pump back, saying I got under false

Insurance companies can do / not do all sorts of things. They often need to
be forced to account for their decisions. I would expect that my pump rep,
in conjunction with my endo, advocate strongly for me. I would expect them
to be a bit "smarter" / more "clever" than the insurance company, while
acting in my behalf. I would expect the rep and health care team to build
the strongest argument possible. If that means emphasizing certain clinical
results, that's fine - that's what I expect. I would also expect them to be
prepared to submit *all* requested info when requested by the insurer.
There's no need to hide anything, and I really don't think the rep intended
this (IMHO).

I think a smart advocate builds and presents a case carefully - I wouldn't
settle for anything less. I would be worried trusting a team that did
anything less.

Bob Burnett

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