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[IPm] What Insurance Companies are looking for
OK Now I am in Massachusetts and deal with Rhode Island and Massachusetts
based Insurance Companies mostly.
But this is the requirements that the Insurance Companies in my area, The
Rhode Island & Massachusetts Medicaid systems and HCFA (Medicare) ask that
our patients meet so that pump therapy is validated for the individual
1. Patient MUST meet these requirements.
- demonstrate ability to self monitor BG levels
> 4x daily
- demonstrated willingness to achieve & maintain
glycemic (BG) control
- Ability to operate the pump
- compliance with diet & insulin regimen
consisting of ___ injections per day and a total
of ____ units of insulin per day.
2. Patients must exhibit two or more of the following:
- Hb A1c level _____ %
- Hx of severe glycemic excursions (associated
with labile DM, hypoglycemic unawareness,
insulin sensitivity, and/or very low insulin
- Wide fluctuations in BG levels preprandial
> 140 mg/dl. Fluctuations range from ____ to
- Dawn phenomenon where fasting BG level often
exceed _____ mg/dl.
- Day to day variations in work schedule,
mealtimes, and/or activity levels, which makes
it difficult to self-manage glycemic control
- Preconception or currently pregnant with a Hx of
suboptimal glycemic control.
- Dx of retinopathy, neuropathy, and/or
- Post-renal transplant w/ suboptimal glycemic
A letter of medical necessity is necessary as well a prescription for the
pump and supplies.
We have found here that the Insurance companies want us to be as specific as
possible with the letter of medical necessity and the exact number of
A sample for a Disetronic 45 day supply and pump prescription is as follows:
Disetronic H-Tron plus V-100 Insulin Pump (color)
1 box Plastic Cartridge (or glass if pt prefers)
5 boxes Tender 1 24"
2 3-volt Silver Oxide Batteries (color) w/key
If you use the rapid or classic you would change it to 1 box of the sets.
This is based on a set change q 2 days which most insurance companies will
I personally recommend that every patient using the Tender get one or two
boxes of the Tender 2 so they have the extra connectors if they should need
A side note, we have one HMO in New England which does not buy the pump for
their consumers, that is Harvard-Pilgrim Health Care. They rent the pumps
from the companies and part of their contract states that the consumer's
pump get upgraded when a new pump is brought onto the market.
Hope this helps some.
CJ Ferry email @ redacted
Fall River, MA
" The reality of the other person lies not
in what he reveals to you but in what he
cannot reveal to you.
Therefore, if you would understand him,
listen not to what he says but rather to
what he does not say. "
- Kahlil Gibran, Sand and Foam
Insulin-Pumpers website http://www.insulin-pumpers.org/
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