Insurance and the Pump

[Lloyd]

I am wondering how low my A1c can be and still get my insurance company to authorize a pump?

If some people were willing to say what their A1c's were when authorized, it might give me some idea what I am up against.

Five months of tweaking my oral meds gave really bad results for me. Two months of Lantus turned out even worse, but Novolog is working very well. I don't know that I can swing the cost of a pump right now, I have a high deductable.
My last A1c was 7.8
The previous one was 8.4
Projections of my next one, in March, are for about a 6.0 A1c, based on my glucose average of 127 for the last month.
So.. I am thinking if I don't get a pump before March, I might be stuck on MDI forever. My doctor thinks I would do well on a pump, I do too.

Your thoughts anyone?

[KritterMom]

I'm a type 2 that recently got a pump. My A1C's were in the 7-8 point range. My dr. fought with the insurance company for 9 months to get a pump for me, but they were denying it because I was a type 2, and they said type 2's don't need pumps. My A1C's weren't very good, but I don't think it was about the A1C's with my insurance company. They finally approved me though. If your dr. thinks you are a good candidate, and you are a type 1, I wouldn't think it would be hard to get one.

[Lloyd]

If your dr. thinks you are a good candidate, and you are a type 1, I wouldn't think it would be hard to get one.

I forgot to say, I'm a type 2. I take 100 units of novolog 70/30

[melissata]

It will depend on the insurance company. The HMO that we just changed to used Medicare and Medicaid guidelines and required a C peptide test. That is their way of being sure not to give pumps to type 2s. My daughter is a type 1 and they made a mistake and told us that her C peptide was too low to qualify her for a pump. It is actually just the opposite and their cutoff was 0.7. You need to be producing very little of your own insulin in order to get that low a score.

[David]

I was in the low 7's before I got my pump. On that basis alone my insurance probably would have rejected a pump, but my endo wrote a letter of necessity based on my records that showed a history of wide swings in my BGLs.

David

[valc3]

My last 2 A1C's were 5.6 and 6.4, the endo sent in the paper work showing the necessity and my insurance company approved it within 24 hrs. Started pumping today.

[Funnygrl]

A good starting point it to get off 70/30 and go on mdi. Proving to your insurance you are willing to inject a lot and count carbohydrates and adjust insulin doses appropriately may prove to them that you are motivated and make them more willing to pay. It's very rare for someone to go from such a simple dosing regimine to a pump directly.

[notme]

Hi Lloyd, it really depends on what your insurance company requires. I am a type one and was on MDI for 14 years before switching to the pump. My A1c was awful, but better than before. When I went in to see my GP my A1c was at the 11 mark. My GP put me on Lantus and humalog and sent me to a nutritionist. I lowered my A1c to 8.5 before going to an endo. The endo had me keep numbers for one month. After that month, my A1c was 8.0 and then I was put on the pump. My first A1c after going on the pump was 6.5. I have remained in the six range since.

Some insurance companies want you to have low A1c's which seem ludicrious to me since you would think they would feel you were doing so well on injections, you wouldn't need a pump. (I don't subscribe to that theory). Some insurance companies want you NOT to be able to control on MDI and only will prescribe if your numbers are awful. Go figure. Most will accept a doctors note of medical necessity. I got that from my endo and have been on the pump since.

Call your insurance and talk to them. It could be they are one of the tough ones that will not prescribe a pump to someone with type two. I hope not.

Good luck to you. I hope you get your pump soon and are on the road to good health.

[Gordonm]

My last two A1cs were 5.8 and 5.9. I have not been above 6.4 in the last 5 years. I just got my pump 3 months ago and could not be happier. I just told my endo I wanted the pump and he wrote out a perscription and the reps and people at MiniMed did the rest. I was approved in 2 days.

[KritterMom]

Wow, I sure wish my experience would have been like that. I guess the fact that I'm a Type 2 made a difference too, but I thought for sure they would just keep denying it. I don't know what my endo said to them, but it must've finally made a difference, 9 months it took to get approved, and about 4 days for the pump to arrive.:dancing2:

[JasonJayhawk]

Lloyd,

Melissa's and notme's advice are right on. It depends on your insurance company, and they don't look just at your A1c level. With Type 2 diabetes, you've got to meet a different set of guidelines than from Type 1, which will likely include the C-peptide blood results.

It completely depends on your insurance company. Some companies, such as Cigna, actually post their policies for the world to see.

You can, of course, get on a pump with no problem if your doctor prescribes it and you pay for it all out of pocket.

Most insurance companies consider several factors, including (but not limited to) glycemic excursions (have you had dangerous lows or highs that resulted in hospital ER visits or admissions?), A1c, frequency of injections (with 70/30 insulin, you're pretty much stuck to 2 injections per day (insignificant compared to the MDI that most pump users have escaped), and current complications (if your kidneys are failing, you have a better chance).

Since you're on 70/30, and the common prescription is for two injections of it a day (for the NPH insulin protamine to cover 24 hours), a pump is unlikely to be covered at all.

FYI, Funnygrl is right -- you'd best get practice with the basal/bolus way of a pump by switching to a different insulin regime if you want to consider a pump in the upcoming years!

Good luck!:five:

[poodlebone]

My A1cs before I got my pump were in the low to mid 5 range. I don't know what my insurance company's requirements are, but if a bad A1c was one of them then I would have been denied. I got those "good" results by having BGs ranging from the 20's to 200's every day. My numbers were all over the place. But, I did test my BG and log my results and my CDE took copies of those. At my very first appointment with her she recommended a pump, sent some paperwork to Minimed, who then contacted me the following week. I faxed them a short form they sent over and my pump was shipped that day. Total time between the CDE suggesting a pump and me having it in my hands was 9 days.

All insurance companies, and even different plans from the same company, are different. I have to say that I am very pleased with my HNMO and it's so much better than the "premium" POP (POS? something like that) plan I had before.

[melissata]

Jason is correct, except that my daughter is a type 1 and already has been on a pump for 4 years and STILL had to have a C peptide done. Made no sense at all, but we still had to do it. Even using Medicare and Medicaid guidelines like they did, there is still an exception if someone is already on a pump prior to changing to that insurance. I found that on line way late in their game though!

[KritterMom]

It's weird with me because, to my knowledge, a CPeptide test was never done on me, even though I personally requested one. The dr.'s just wanted to call me a type 2 because I was dx'd when I was pregnant 20 years ago with my last child. My mom was a type 1, and my doc thought I might have Type 1 tendencies, but no one ever did a cpeptide test. I thought that was strange.

[Funnygrl]

I had a c-peptide test before I got my pump and it was almost normal. A year later I suspect it wouldn't be though. And my insulin requirments have gone up 4x since then.

[Lloyd]

A good starting point it to get off 70/30 and go on mdi. Proving to your insurance you are willing to inject a lot and count carbohydrates and adjust insulin doses appropriately may prove to them that you are motivated and make them more willing to pay. It's very rare for someone to go from such a simple dosing regimine to a pump directly.

I tried Lantus first, the results were very bad, it seldom got me under 200, and then only in the morning. It was quite painful.

At the dose of Novolog I'm on, I have to split the AM dose to 2 sites, so I am at 3 injections daily.

My doctor thinks Lantus could be made to work, but it would take multiple injections daily, which pretty much defeats the purpose of Lantus.

I test 5 or 6 times a day, 10 when adjusting the dosage. I have been counting carbohydrates for 10 years now. I keep good records, my doctor has printouts of every glucose test I have done for the last 3 years.

Thanks for the help everyone, I'll let you know how it comes out.

[poodlebone]

My CDE also ordered a c-peptide test, as well as the antibody test, but it wasn't an insurance requirement. She just didn't believe me when I said I was Type 1 because I was overweight at the time. She kept asking me who told me I was Type 1. I said that would be the endo in the hospital when I was disgnosed, in DKA, and kept for 8 days.

My test results came back showing I made absolutely no insulin and had zillions of antibodies. The CDE never questioned me again, especially after I lost all the weight once I got my pump.

[KritterMom]

I had the same problem. I'm overweight, and therefore assumed a type 2. Then I ended up in the hospital with DKA. However, they still didn't do the testing. My mom was a type1, and they said I might have genetic type 1 tendencies, but thats as far as it went.

[Mollymay]

Medicare required a fasting blood sugar and c-peptide. The fasting must be less than 200 . I don't have a pancreas, but medicare required a c-peptide test anyway.

[Funnygrl]

I tried Lantus first, the results were very bad, it seldom got me under 200, and then only in the morning. It was quite painful.

At the dose of Novolog I'm on, I have to split the AM dose to 2 sites, so I am at 3 injections daily.

My doctor thinks Lantus could be made to work, but it would take multiple injections daily, which pretty much defeats the purpose of Lantus.

I test 5 or 6 times a day, 10 when adjusting the dosage. I have been counting carbohydrates for 10 years now. I keep good records, my doctor has printouts of every glucose test I have done for the last 3 years.

Thanks for the help everyone, I'll let you know how it comes out.
No, NO, NOOO.

Lantus RARELY works with only one shot a day. That's why you never got below 200. And the point of Lantus IS NOT to only take one shot a day. It's to get a flat basal, on top of which you can take bolus shots, and therefore get tight control, and mimic a pump.

Doing this will show your insurance that you have the knowledge needed to pump (you can carb count and all that jazz), and that you are willing to put the effort forth.

When I say carb counting, I mean counting the carbs, then using a carb ratio to determine dose.

I am hugely not a fan of going from 1 to 2 shots a day to a pump. I think multiple daily injections should be a must before a pump. Granted, you don't need to do it long, but if gives you a good foundation in the basics of using insulin to manage your diabetes. Plus, if your pump fails, you need it as a back up.

[Keezheekoni]

I have Aetna for insurance. The policy type is the Open Choice PPO. Normally I hate my insurance company, however because I live in WA state, the insurance commissioner has a mandate about diabetes. This mandate forces insurance companies who want to do business in WA state to cover anything and everything related to diabetes care, of course your plan limits and deductibles apply.

My point is that even though Aetna says in their policy bulletin that they require c-peptide, GAD tests, etc., and that you must have a certain number of A1c tests over 8, I didn't have to "prove" anything because our state mandates that if my doctor believes that it's necessary then Aetna must cover it. (Unfortunately for me, my state doesn't mandate gastric bypass for morbidly obese people. I guess I can't win them all!)

So, definitely check into your state mandates. Then do what funnygirl recommends because it really is difficult to understand pumping when you are only taking two or three shots a day. I find it incredible that you can do that. I had different ratios for my humalog all day long. Two shots of lantus as well. I was taking up to 12 shots a day at times...

[Lloyd]

No, NO, NOOO.

Lantus RARELY works with only one shot a day. That's why you never got below 200. And the point of Lantus IS NOT to only take one shot a day. It's to get a flat basal, on top of which you can take bolus shots, and therefore get tight control, and mimic a pump.

Plus, if your pump fails, you need it as a back up.

Lantus didn't get me closer than 100 points above what I should be after 12 hours of fasting, so it wasn't working for me as a basal, at a dose of 100 units. Also it was excruciating, even spliting it into 2 50 unit injections. Even if it had worked, and I could have added bolus injections, the pain was too great. No way could I have increased the dosage without adding a third injection, which kind of defeats the stated purpose by the developer of Lantus, doesn't it? My doctor said essentially the same thing.

My computer says my average glucose for the last 2 weeks is 118 (I use one meter at home, one at work), so I am doing pretty well with novolog. My average for 2006 on oral meds and later Lantus was 195. I am loosing weight and am not as hungary a few hours after meals as I used to be.

So... Novolog should work as a backup if I have a pump breakdown I would think.

I'll just have to see what insurance comes back with.

I sure don't have all the answers, and appreciate the input. Due to the pain, almost ANYTHING would be better than Lantus, in my case. All I can say is on a pain scale of 1 to 10, it was a 9 for about 15 seconds.

Thanks

[aeromarv]

Teoretically, the insurance should continue to pay even if you improve your control. That means less cost for them later from possible complications. Of course that's the theory.

When I lived in Maryland, I looked in to the pump. Blue Cross Blue Shield of MD would only pay if your A1C was lower than 7. If it was higher, you needed to be able to show progression towards the lower numbers. So if you were losing control, your A1C would go up and if you didn't correct it, they would stop paying and you'd have to go back to mdi.

[aeromarv]

No, NO, NOOO.

Lantus RARELY works with only one shot a day. That's why you never got below 200. And the point of Lantus IS NOT to only take one shot a day. It's to get a flat basal, on top of which you can take bolus shots, and therefore get tight control, and mimic a pump.

Doing this will show your insurance that you have the knowledge needed to pump (you can carb count and all that jazz), and that you are willing to put the effort forth.

When I say carb counting, I mean counting the carbs, then using a carb ratio to determine dose.

I am hugely not a fan of going from 1 to 2 shots a day to a pump. I think multiple daily injections should be a must before a pump. Granted, you don't need to do it long, but if gives you a good foundation in the basics of using insulin to manage your diabetes. Plus, if your pump fails, you need it as a back up.

Agreed. I was on Lantus once a day with 3-4 novolog shots too. That is pretty close to the pump without being on the pump. The pump will take over the basal with tiny amounts of the fast acting and take care of your food with large bolus of fast acting. Just like a working pancreas.

[Lloyd]

Teoretically, the insurance should continue to pay even if you improve your control. That means less cost for them later from possible complications. Of course that's the theory.

When I lived in Maryland, I looked in to the pump. Blue Cross Blue Shield of MD would only pay if your A1C was lower than 7. If it was higher, you needed to be able to show progression towards the lower numbers. So if you were losing control, your A1C would go up and if you didn't correct it, they would stop paying and you'd have to go back to mdi.

If I run into that situation, no problem. If I took an A1c right now it would be about a 6.7, my BS is getting better all the time. My last one was 7.8 (late Dec) and 8.4 before that. It all depends on their criteria and rules.

[Funnygrl]

If you have trouble with Lantus stinging, I recommend Levemir. That would be two shots a day, plus fast acting insulin with meals, but it doesn't sting, and it would, again, simulate a pumping type regimen.

I seriously recommend you work on your insulin resistance some before starting a pump. Pump's are great things, but your insulin needs are VERY high so you have some underlying issues there that will improve your overall control and health if you can address.

[Funnygrl]

Also, when you say you will use Novolog if your pump fails, do you mean Novolog 70/30 or plain old Novolog? Plain old Novolog would be what you would use in your pump, so what you would have on hand, but would require an injection every 2 hours if your pump failed to stay on top of things.

If you mean 70/30, that's very hard to go back and forth from pumping on, because conceptually, they are two very different regimens, and as your insulin needs change, you'll have no clue how much to take.

[Lloyd]

If you have trouble with Lantus stinging, I recommend Levemir.

I suggested that to my doctor some time back, he felt Novolog mix was the better route for me to take.

It IS working well, if my past months average of 125 were to extend forward 2 months, that would suggest a 5.7 or 5.8 A1c in March. Going from a 7.8 to a 5.8 would be no small improvement.

I just don't like all the inflexability, I could loose a lot more weight with a pump, many times a taco salid for lunch fills me up, but I have to eat more carbs.

[Funnygrl]

I suggested that to my doctor some time back, he felt Novolog mix was the better route for me to take.

It IS working well, if my past months average of 125 were to extend forward 2 months, that would suggest a 5.7 or 5.8 A1c in March. Going from a 7.8 to a 5.8 would be no small improvement.

I just don't like all the inflexability, I could loose a lot more weight with a pump, many times a taco salid for lunch fills me up, but I have to eat more carbs.
It sounds like you are doing well. But my original point kind of got lost in all this. You wanted to prove to your insurance company that you are a good pump candidate. Almost without fail, people using 70/30 are not considered good candidates, so changing to MDI would make you a much more desirable candidate for pump funding.

[Lloyd]

Also, when you say you will use Novolog if your pump fails, do you mean Novolog 70/30 or plain old Novolog? Plain old Novolog would be what you would use in your pump, so what you would have on hand, but would require an injection every 2 hours if your pump failed to stay on top of things.

If you mean 70/30, that's very hard to go back and forth from pumping on, because conceptually, they are two very different regimens, and as your insulin needs change, you'll have no clue how much to take.

I could take novolin NPH, and novolin as a backup, I have no problem with that. I have a HUGE problem with Lantus.
Anyway, the ball is rolling so we will see what happens. I have such a high deductable that it is not that much more for me to pay for the pump, if it comes to that.
-Lloyd

[lilituc]

As everyone else said, it depends on your insurance. Some will only cover a pump if your A1c is low and some only if it is high. It makes no sense to me.

[Lloyd]

It sounds like you are doing well. But my original point kind of got lost in all this. You wanted to prove to your insurance company that you are a good pump candidate. Almost without fail, people using 70/30 are not considered good candidates, so changing to MDI would make you a much more desirable candidate for pump funding.

I see your point.

I want the best glucose situation I can get with the fewest pokes.

Excuse me while I exagerate a bit, but it seems to me like asking to have your foot cut off so you can be approved for a wheelchair. :egg:

If they don't approve, I am stuck with many more injections than I have now. I am not ready to take that risk at this time.

[Funnygrl]

I see your point.

I want the best glucose situation I can get with the fewest pokes.

Excuse me while I exagerate a bit, but it seems to me like asking to have your foot cut off so you can be approved for a wheelchair. :egg:

If they don't approve, I am stuck with many more injections than I have now. I am not ready to take that risk at this time.
Do you have a problem with injections? Many people on this board do like 6-8 a day long term and have no problem with that. I was just wondering, because if there is a specific reason you are so adament about not doing many, some here might be able to help so it's easier.

[Lloyd]

Do you have a problem with injections? Many people on this board do like 6-8 a day long term and have no problem with that. I was just wondering, because if there is a specific reason you are so adament about not doing many, some here might be able to help so it's easier.

I disliked my 150th injection just as much as my first. I hate needles. No fear, dread would be way to strong a word for an injection, but would apply when I think of 6 - 8 a day for the rest of my life.

Some of the injections are moderately painful, more than half don't hurt at all. I also really don't like what injections do to lifestyle, things like eating out.

Hey, I got up this morning and went out and started the car in -12 and windy weather. I can do it. It doesn't get that cold more than a half dozen times a year.

That doesn't mean I am willing to move to Pt. Barrow, Alaska.

I will be going through a distributor for a pump rather than Smith's Medical, the distributor may know something about my insurance requirements.

I'll do what is necessary to treat my diabetes. I always have. If 6 - 8 injections become necessary, I'll do it.

I won't !@#$!@#$!@#$ like it one !@!#!@#!@#$ bit but I'll do it.

I have DP, 5 am 8 am readiangs from 125 to 180, no pattern at all to it that I can discern. A pump could knock all morning bg down by 30 to 40 points safely. I get to sleep about 12 or 1 am, so waking up at 6 am to get an injection is a bad idea. Breakfast is 8 am, I work 10 - 6.
I'd really like to be able to treat my DP.

Thanks for listening!

-Lloyd

[Funnygrl]

It does sound like a pump would be good for you. Have your read Pumping Insulin by John Walsh or Think Like a Pancreas by Gary Schiner? Both books are excellent.

[Lloyd]

It does sound like a pump would be good for you. Have your read Pumping Insulin by John Walsh or Think Like a Pancreas by Gary Schiner? Both books are excellent.

I plan to read both. I have Insulin Pump Therapy Demystified on order, it should get here in a few days. I don't know how good it is but I suspect all the readings will help.

I have figured carbohydrate ratio using the 500 rule and corrections using the 1800 rule, and I bought a food scale to make my carb counting more accurate.

In a recent email, my doctor said "You are becoming a champion success story". I'm not sure I believe that, but I am sure it was nice to hear. LOL

-Lloyd

[Lloyd]

It does sound like a pump would be good for you. Have your read Pumping Insulin by John Walsh or Think Like a Pancreas by Gary Schiner? Both books are excellent.

Demistified had not shipped from Amazon, so I canceled that and switched it to your suggestions. The two books was just enough to get me free shipping :adore:

Thanks,

-Lloyd