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[IP] Medicare requirements



Sue (dalgal),
Here's some info about Medicare and insulin pump coverage.  Someone else may
have posted this already, but in case they didn't here's detailed info plus
the website. Info pertinent to someone already pumping is preceded by
********.
Marj; Mike; and "Ace, the PP" (portable pancreas)

Appendix A

COVERAGE ISSUES - DURABLE MEDICAL EQUIPMENT 60-14
60-14 INFUSION PUMPS

THE FOLLOWING INDICATIONS FOR TREATMENT USING INFUSION PUMPS ARE COVERED
UNDER MEDICARE:

External Infusion Pumps.--

Continuous subcutaneous insulin infusion pumps (CSII) (Effective for
Services Performed On or After 4/1/2000).--

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

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

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:

A.
Glycosylated hemoglobin level(HbAlc) > 7.0%
History of recurring hypoglycemia
Wide fluctuations in blood glucose before mealtime
Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl
History of severe glycemic excursions

B.
**********The patient with Type I 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.
Type I diabetes needs to be documented by a C-peptide level < 0.5

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

The pump must be ordered by and follow-up care of the patient must be
managed by a physician who manages multiple patients with CSII and who works
closely with a team including nurses, diabetes educators, and dietitians who
are knowledgeable in the use of CSII.

Subcutaneous insulin infusion pumps will continue to be denied as not
medically necessary and reasonable for all Type II diabetics including
insulin-requiring Type II diabetics.


Medicare Coverage Policy ~ Decisions
C-Peptide Levels as a Criterion for Use of the Insulin Pump (#CAG-00092A)
Decision Memorandum
http://www.hcfa.gov/coverage/8b3-ss2.htm

Date: Mon, 05 Nov 2001 04:00:13 +0000
From: "sue depinto" <email @ redacted>
Subject: [IP] C- Peptide Test Why & What

Next Feb. I will go on Medicare. They require a C-Peptide test, right? To
pay for pump supplies!?!? Can someone please tell me why they require this
test and exactly what it shows about you. I know we talked about it a long
time ago and I forget what was said. I go to the doctor's tomorrow and will
probably have to get the test done then. Thanks,

Sue (dalgal)
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