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Re: [IP] #@$%$Insurance

> I got a call from my son's endo today and our insurance company
> wants his insulin adjustments for the last year to determine if
> enough has been tried to bring him under good control without a
> pump.  Sounds like a Catch-22 to me- If he is under good control, he
> doesn't need a pump;  if not, he hasn't had enough 'adjustments'

It is a catch 22 for them if you work it right.

>> doesn't need a pump;  if not, he hasn't had enough 'adjustments'

He is not an "experimental subject' on whom 40 year old treatment 
regimens need to be tried that are known to not work well.

Good hbA1c's are an indication of a patient that works hard at
control and is a GOOD candidate for a pump, not the other way around.
They need to understand that (they do, but tell them again).

The flip side of that argument is that for someone that has had 
difficulty with control, the pump provides the best and most 
straightforward method to dramatically improve control and hbA1c's.
The majority of participants in the DCCT switched to insulin pumps
because tight control was easier to achieve. This is an obvious 
argument that a pump is the first and most appropriate choice to 
improve both short and long term health and complication prognosis 
for a person with diabetes.

Most insurance policys are written in a manner that says all normal
medical expenses are covered unless experimental or specifically
excluded. Since you are unable to negotiate the terms of the policy
and must accept what they provide for policy language, the courts have
taken a strict interpretation of the language to mean that if the
insurance company forgot to mention something, they are obligated to
provide it. Bottom line, pumps and supplies are covered unless there
is specific language to the contrary. You may have to appeal, you may
have to involve the insurance commissioners office or state department
of labor in the case of a union sponsored medical plan, but DON'T give
up, don't take no for an answer.

The insurance company can not contravene a doctors orders for 
treatment unless those orders are patently unreasonable and 

Address the quality of life issues, sick days, etc...
point out the rigid schedule, eating when not hungry, not eating when
hungry, problems with adolescence, etc... Mention the cost of ER
visits for low blood sugar epsiodes caused by long term insulins. Make
sure you GO to the ER for these problems. Might as well sock it to
'em. I know it is not convenient to do this, but it may be necessary
to motivate the insurance company.

Keep up the fight.
BTW, it took me almost a year and a half of this BS to get BS of 
Calif to approve Lily's pump. 
email @ redacted
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