More not so good news…

Today I received a note from my employer’s insurance broker. They are trying to help me get insurance coverage of an insulin pump and continuous glucose monitor system.

Attached was the criteria Great West uses to decide who gets coverage and who does not.

Policy: Criteria #1
A. Continuous subcutaneous insulin infusion (CSII) with an external insulin pump, including OmniPod®, is considered medically necessary and is covered as durable medical equipment (DME) when all the following are met:
1. The patient has very low endogenous insulin levels as demonstrated by the fasting C-peptide requirements* as defined below OR is beta cell autoantibody positive (Levels only need to be documented one time in the medical record), unless there is an unequivocal history of diabetic ketoacidosis (DKA)

Very low endogenous insulin levels are a diagnosis of Type 1 diabetes, not Cystic Fibrosis Related Diabetes.

Beta cell autoantibody positive would lead to a diagnosis of Type 1 diabetes, not Cystic Fibrosis Related Diabetes.

DKA is not common in patients with Cystic Fibrosis Related Diabetes. (thank goodness for me!)

I do NOT HAVE TYPE 1 DIABETES!…. is there ever an exception to the rule?!!!

As if I didn’t have enough to deal with already, why won’t my insurance realize that not everyone fits in their little square box of “average”?!

To continue on…

Here is the policy of who receives coverage for a continuous glucose monitor:

“The combination insulin pump and continuous blood glucose monitoring system is covered when the cost of the combination device is not greater than the cost of the pump alone”

I am in disbelief… did I read that right?! Insurance will pay for a CGMS only if it is FREE?! WHY WOULD I NEED COVERAGE IF IT WAS FREE?!!!

The logic is not making any sense to me today… sigh.

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This entry was written by Salty and posted on March 12, 2008 and filed under Challenges, diabetes, insulin pump, insurance.
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2 Comments so far (Add 1 more)

Dean – There is no way on earth I could thank you enough for your contribution to my needs.
I truly hope the best for you and your family.
Thank you so very much.

1. aspen on April 3rd, 2008 at 4:40 pm
Aspen,
We have dealt with the same kind of health care “coverage” that seems to use every loophole they can to avoid paying benefits. Our 15 year old daughter has CFRD. She was diagnosed with CF when she was 9 mos. old and diabetes when she was 12. It’s pretty clear insurance companies aren’t invested in helping people . . . they seem to use every tactic they can to avoid paying benifits, but keep increasing their rates. Hmmm – sounds sort of like Organized Crime!?
We wish you the best and we will support you in every way we can. Please find our gift towards your new insulin pump and know you are loved even by those who don’t know you personally. We can do together what none of us can do alone!
You have great strength to do what you are doing here and in your life. Thank you for what you have given us.
With love and respect,
Dean, Shelley, Jessie, and Allie

2. Dean on March 13th, 2008 at 2:32 pm