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Re: [IP] Tricare Military Denied (long reply)
In a message dated 10/31/99 6:54:06 AM US Mountain Standard Time,
email @ redacted writes:
<< I am sorry . . . I am rambling. I'm just so upset. Do I have to be on
dialysis or blind before they consider me?? >>
Of course you're upset. Fighting the insurance company, and yours being
Military must be even harder, is often times a bigger problem than the
I am not on Tricare or military related but I thought you might find this
insurance story helpful in your fight.
When I got my pump four years ago, I had a very good CDE who fought my
insurance battle with the HMO (Intergroup). They officially did not cover
pumps at the time. We tried anyway. She put together from my lab work, Dr's
reports a very convincing argument dollar wise for them. The insurance
company wants to know what the bottom line is. They want to save money. The
don't give a crap about your quality of life, etc.
Important things to include are the potentially most costly complications you
will be facing soon, like your kidney status. Get some pricing on what
dialysis costs. Put the dollars in front of their faces. I'm guessing
$40K/yr???. Then the cost of a transplant, with the associated hospital stay
and rejection drugs. That's got to be large. Show your lab results with the
resulting deterioration of your kidneys. Can you get copies of all these?, I
think they have to give them to you. Then go on to the next complication you
are facing, maybe Retinopathy.
Then show your dedication to "complying to your treatment plan" by showing
your log books of MDI which include bgs before meals, and post-prandials
(sp?) and carbs eaten. Point our the effort you are taking to try to "comply
with the treatment plan" and you can't get the level of control (show the
A1cs) that would allow you to avoid these costly complications. Stress that
MDI cannot give you the level of control necessary to "comply with the
treatment plan". Point out that you are doing everything in your power to
comply but they are not supplying you with adequate tools. Show them stats
of peoples A1cs coming down into normal range after pumping, the pump
companies should have these.
Then show them info from the DCCT that states that having your A1cs within a
certain range will slow your complications or prevent them from happening.
Then take the grand totals, your expense of MDI plus complications, oh maybe
$100K/yr in the worst case scenario, and compare it to the cost of the pump,
$10K/yr with the initial purchase and all the supplies.
I got mine this way as did about 6 others that year from Intergroup. Another
friend from the support group got one approved through another HMO (Cigna).
She had to attend several hearings after appealing 3 times. But she did get
her pump. The HMO in this area have loosened up considerably since we went
through this. Now they can see the dollar savings.
Stand up and scream!!!!! Maybe the local new would be interested too.
Best of luck,
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