[Previous Months][Date Index][Thread Index][Join - Register][Login]
[Message Prev][Message Next][Thread Prev][Thread Next]

[IP] Medicare and pumping

Since there seem to be more requests related to Medicare pump coverage,
thought it would be good to post info on Medicare requirements.  This site
deals with the change in the accepted C-peptide level, and also has the
criteria which Medicare uses to determine a person's eligibility for
Medicare coverage of a pump.

An important note, is that Medicare only covers one (1) infusion set a week,
though covers as many reservoirs as needed (yeah, no sense to it).  So if
Medicare is one's only or primary health insurance, then one could have to
pick up the expense of the additional infusion sets needed weekly if the
business supplying them provides written notification that more than 1 per
week is not covered by Medicare (often a secondary insurer won't pay for
something Medicare denies, but some Diabetes supply companies will write off
the cost for the additional sets so one has to check with any secondary
insurer and the company sending supplies to find out).  Sometimes, the
request for more than 1 per week does slip through the Medicare system and
gets approved.  Also, letters to congressmen and senators on this issue
could help.  All pump companies, many supply houses, many doctors have
supplied info on the importance of more frequent infusion set changes.




External Infusion Pumps.--

An external infusion pump and related drugs/supplies are covered as
medically necessary in the home setting in the following situation:
Treatment of diabetes

In order to be covered, patients must meet criterion A or B:

(A)    The patient has completed a comprehensive diabetes education program,
and has been on a program of multiple daily injections of insulin (i.e. at
least 3 injections per day), with frequent self-adjustments of insulin dose
for at least 6 months prior to initiation of the insulin pump, and has
documented frequency of glucose self-testing an average of at least 4 times
per day during the 2 months prior to initiation of the insulin pump, and
meets one or more of the following criteria while on the multiple daily
injection regimen:

(1)    Glycosylated hemoglobin level (HbAlc) > 7.0 percent
(2)    History of recurring hypoglycemia
(3)    Wide fluctuations in blood glucose before mealtime
(4)    Dawn phenomenon with fasting blood sugars frequently exceeding 200
(5)    History of severe glycemic excursions

(B)    The patient with diabetes has been on a pump prior to enrollment in
Medicare and has documented frequency of glucose self-testing an average of
at least 4 times per day during the month prior to Medicare enrollment.

Diabetes needs to be documented by a fasting C-peptide level that is less
than or equal to 110 percent of the lower limit of normal of the laboratory'
s measurement method. (Effective for Services Performed on or after January
1, 2002.)

Continued coverage of the insulin pump would require that the patient has
been seen and evaluated the treating physician at least every 3 months."

Marj; Mike (I'm not into computers, but glad to be on this list); and "Ace,
the PP" (portable pancreas)
for HELP or to subscribe/unsubscribe, contact: HELP@insulin-pumpers.org
send a DONATION http://www.Insulin-Pumpers.org/donate.shtml