Comments on: Denied again – Update – the letter

By: aspen

aspen — Thu, 03 Apr 2008 23:48:27 +0000

Hi bkj1981,
Thanks for the advice.
I will ask my doc about those alternative tests, although it is in Great-West’s policy that I have to have a low C-Peptide level, or show autoantibodies (which is only a case for Type 1 diabetes, not CFRD) to receive insulin pump coverage.

We are about to begin the last and final appeal, which may have to take a trip to Columbus Ohio to see another specialist who is familiar with CFRD to get a second opinion.

By: bkj1981

bkj1981 — Thu, 20 Mar 2008 23:53:01 +0000

I am one of those “professionals” that works on getting insulin pumps for people with diabetes at a large company. I have yet to come across any particular patient that had, to my knowledge, CF related Diabetes. In my experience it really depends on the type of insurance that you carry. Most insurances are not covering the Continuous Glucose Monitoring System(CGMS) for the same reason as the denail letter you have received. We have found with some insurances that if you and your doctor get involved in the appeal process, sometimes called a pier to pier review, the claim can be overturned/approved but it will take some work on both parts. It can be a lengthy and sometimes difficult process but if resulting in an approval can be very beneficial for you.

Another thing with the lab work that is drawn that in instances that the C-Peptide levels are within normal range is to try the Alternate labs that should be acceptable. Those are; Insulin Autoantibody, Islet Cell or Beta cell, and a Gluctamic Acid Decarboxylase Autoantibody(GAD AB) test. You can google each of these to get the definition of the purpose for the test.

I hope this helps and if you would like you can email me directly and I can try and help you more.

By: in search of balance

in search of balance — Mon, 18 Feb 2008 18:47:30 +0000

When I needed approval, I got the pump company to apply for it. They make quite a bit of money when a pump is approved, so they work quite hard to ensure that it is. If your insurance never approves pumps for the less common forms of diabetes, it may not work, but it might and it would save some stress for you! There are also some pretty good payment plans if it turns out that a pump is something you’d be willing to pay for out of pocket. I would really recommend contacting a pump company… and probably the biggest in the USA, Minimed.

I’m sorry to hear about this. Extra stress is the LAST thing that a person struggling with chronic illness needs. I hope that you find a resolution that works well for you, and let me know if there’s any way that I can help you out!

By: Jesse Petersen

Jesse Petersen — Mon, 18 Feb 2008 13:50:23 +0000

My 2 cents:

If I were you, I’d schedule a clinic appointment and bring your letters with you (or just call to see if you can see your CF doctor during some kind of hospital office hours) and ask if it would be possible to get a letter arguing the conclusions of the “expert” who might be operating on false assumptions.

The “expert” is likely only book educated from old studies on the effects CF has on the endocrine system. My doctor said there is one major informational or medical breakthrough every month that I’d bet passes by every medical person outside the CF/respiratory arena.

There simply aren’t enough of us to warrant brush-up training on our issues, and there sure the heck aren’t enough of us with CFRD for all the specialists to know about CFRD. I didn’t know about it until my wife found your blog, so it wouldn’t surprise me if dozens of CF specialists aren’t recognizing it yet. I knew diabetes is a risk based on our high simple carb diets, but for it to be anything other than Type 2 diabetes was news to me.

If this doesn’t work, in all seriousness, you might have to look for an employer that offers another health insurance. I went 3 years using a self-insured policy with Aetna to get the coverage I needed, despite the crippling premiums. It was taking close to 30% of my monthly salary, but it was what had to be done to get the meds I needed.

Still pulling for you from Florida.