[duck]

Well, I have decided after much soul-searching to go ahead and get a new pump. On Monday, I'll be authorizing my insurance's DME supplier to proceed with acquiring a MiniMed 722...

Since my visit with the new opthamologist last month, where he found the beginnings of "changes" in my retinas, I've not been the same. I know there are plenty of treatments available for us who might suffer these issues, but part of what has been getting to me is my little voice saying "You already work hard at this, and it's still beating you..." I know I could tweak my routines even more, but the fight just seems to finally wear on you. Perpetual war probably is as bad for the person as it is for society in general. And after re-reading the essay Archimeech posted years ago (http://www.diabetesforums.com/forum/...ologists.html?, it occurred to me I am nearly 17.5 years with this disease...

17. To everyone who studies the results of the DCCT without the eyes of the blood sugar police, the most striking finding is the extremely wide variation in complications among different patients at the same average blood sugar level. This points to the importance of factors OTHER than the blood sugar level in causing compliations. This, combined with the fact that some rare patients have been observed to have diabetic complications but no trace of diabetes, and that there is a very high peak of new onset cases of diabetic nephropathy 17.5 years after onset of diabetes, regardless of the level of blood sugar control, suggest that the blood sugar control is being overemphasized in therapy.

So here I am, hip-deep studying for a massive exam I have to take next month, wondering if it is all downhill from here at the ripe old age of 34, with two kids and what should otherwise be the best years of my life ahead of me...and my brain is starting to look for the panic button.

So, my care team says this development with my eyes, however "minor", constitutes medical necessity for an aggressive change, that change being CGMS. My insurance agreed with my doc, but of course he asked for and they approved the 722 pump, but not the built-in CGMS. They will approve the Guardian if my doc says it is medically necessary.



At any rate, I'll pay out of pocket if I have to for the CGMS. I'd regret being debilitated early in life because I got cheap when the time for the right decision came.

And as long as I am venting and ranting, as of yesterday (Friday) my consulting gig with the people in the 5-sided building is up--it's a long story, suffice it to say government contracts are just assanine...even when the client wants you to stay, it's just not as simple as allocating a slot with money to pay your company for your position. So my concern now is, I could get fired or laid off soon--that in and of itself doesn't worry me, I have skills and abilities that will get me rehired within two weeks by another Beltway Bandit--I could always contact one of the other contracting firms that are still entrenched with my former client...But my concern is, the next insurance for my next employer will say "Pump? Wazzat? An Aerosmith album? 'Love in an elevator!' Great song!" So, circumstances have forced my hand into pushing for this pump now as opposed to waiting.

Sigh. It's not like I had enough on my mind with this exam coming up. I'll get over this shortly, but right now I find myself constantly shaking my head and brooding.

/rant. Off to study some more late on a Saturday night.

[BlueSky]

Sorry to hear your disconcerting news. I remember agonising over the appearance of micro-aneurysms in an eye scan about 5 years ago. I have managed to keep the HBA1c below 6.5% since then and the problem has not progressed. Hearing about people with even lower HBA1c levels having major problems with retinopathy is indeed mystifying. I am sure that there are other factors involved, like genes and stress. T2s seem to have greater problems at lower HBA1cs possibly because of higher insulin levels.

Anyway, good luck with the new pump and doing what it takes to stabilise/reverse that retinopathy. At the end of the day, we can only do our best and make the most of the cards we have been dealt. And the only way to be happy is to live in the present.

[kgm0612]

Duck............You're gonna love that new pump once you get it going and I can bet in a month or two you're going to say "I should have started pumping YEARS ago".

Good luck!

Karen

[duck]

This will be my third pump, actually. I probably should have never MM in retrospect, but you (hopefully continue to) live and learn.

[Funnygrl]

Duck, is insurance going to pay? I find out tomorrow or Tuesday if I can get a 522. I'm honesty not optimisitc. I really want a CGMS, but I'll find a way to get one whether I get a 522 or not, and I love my Cozmo, so I'll be find it they won't.

[jeggeman31]

Duck I will also be speaking to my ENDO about changing over to the 722 with the CGMS.

Good Luck

[duck]

Originally Posted by Funnygrl

Duck, is insurance going to pay? I find out tomorrow or Tuesday if I can get a 522. I'm honesty not optimisitc. I really want a CGMS, but I'll find a way to get one whether I get a 522 or not, and I love my Cozmo, so I'll be find it they won't.

They are paying their rate on the 722, but seem to be confused as to whether they will pay for the CGMS activation on the 722 (apparently, MM charges about $1000 to activate the CGMS on the 722, or $1339 for the Guardian...with the Guardian at that price, you get three sensors and the transmitter, with the 722+activation fee, you get ten sensors, the transmitter, etc.) As stated, they apparently will assist with paying for the Guardian, AND 722. I know it took me maybe twenty minutes to sort all this out, but for an insurance company to not understand the minor differences in the two systems is beyond me. I'm still paying for a decent portion of it all, but that's fine. We're not rich but I need to count my blessings and realize we're not poor, either.

And, if I have to, I'll pay MM the $1000 to get the CGMS turned on with the 722...what's funny is my insurance told me they would NOT cover the replacement sensors if I use them with the 722; but they WILL cover them for the Guardian at their DME rate. What's the difference? None. So I'm going to ask my endo to write me a prescription for the sensors for a Guardian. Again, the confusion is amazing.

I don't know if I asked, but why not get the Guardian, then? I wasn't opposed to doing that, except my care team talked me into the 722 (and actually, my wife too).

It is my understanding that *most* insurance companies will assist in acquiring a pump if there is a valid medical necessity--a change in condition is considered valid.

Originally Posted by jeggeman31

Duck I will also be speaking to my ENDO about changing over to the 722 with the CGMS.

Good Luck

See my last note above...and good luck to you too.

[Funnygrl]

My insurance told me they would pay for a pump for me if I got a script from my doctor (check) but I'm worried I'll run into problems because I have a perfectly good pump that has 2.5 years left in warranty. I dunno, guess I'll see tomorrow.

[duck]

Well, there are plenty of charity options for perfectly-functional pumps. Smiths Medical took my 508 and refurbished it, I'm meeting with my local MM rep Wednesday at a seminar MM is putting on here in Manassas and I'm going to inquire with her what the most benevolent thing I can do with this pump I have now is...As we all know, I've not exactly had a great experience with it, but others have, so it can serve its purpose.

[Funnygrl]

I wanna keep my Cozmo though since I like it better as a pump. I just want the **** CGMS.

[duck]

And they won't cover the Guardian at all?

Actually, you'd be in for something of an uphill battle with your insurance company (I bet) if you inquire about the Guardian. I called mine twice before I decided to pay out of pocket for the Guardian. Then I decided to call the local MM rep who had contacted me months ago since I was still in their records (but no longer using their equipment). She told me I should call my insurance one last time, and ask what would happen if I had a letter of medical necessity and evidence of a change in condition, would a CGMS be approved then? I got a really smart person that third time I called (and of course I'm going to call her smart since she helped me out), and she told me her immediate documentation said no, but there were notes that indicated it was not a definite no...so she contacted a supervisor and then her support line, who interpreted her info that she had as "approved with statement of medical necessity". She documented all that, thankfully.

Of course, twice since then (and it was only July 6 when I had that conversation) I've had reps at my insurance company tell me Guardian is NOT covered under any circumstances. It's been nice to point them to the notes from my call earlier in the month and listen to the back-tracking afterwards.

I'm just putting this out there in case you or someone else wants to try this as well...

[Funnygrl]

My insurance is being silly. I asked about coverage for "continuous glucose monitors." Oh yes, we cover at 100% states them. I don't trust them though, so I keep prodding. "It's just a glucometer, right?" Uhm...wrong. So then they tell me they need the billing code. No billing code? Ok, we won't cover then. Alas, I expected this. I ask if I can pay out of pocket and be reimbursed. No go. They tell me they'll reimburse me in January if and when the codes come out, maybe. So I figure the pump add on is the cheapest way to go if I can get the pump covered, and I'll submit for reimbursement when the codes are out.

[duck]

Since this stuff is publically available for DL on my insurance's website, I'm gonna copy and paste here (in reference to their Position Paper on Pumps, Pumps with Glucose Monitors that communicate with them, and Pumps with CGMS)...Funnygrl, unfortunately, there doesn't seem to be an HCPCS code for CGMS yet:

CSII-BGM Systems with Continuous Glucose Monitoring: The MiniMed Paradigm® REAL-Time Insulin Pump (Medtronic MiniMed, Northridge, CA) is currently the only device that includes a continuous glucose monitor as opposed to the standard glucose monitor. It is used in conjunction with the Guardian RT® Continuous Glucose Monitoring System (Medtronic MiniMed, Northridge, CA), FDA-approved April 7, 2006 and June 14, 2006, respectively. This combined system received PMA approval, as implantable infusion pumps or closed-loop devices require PMA by the FDA.

Literature Review:
CSII-BGM Systems: Minimal literature has been published specifically related to the clinical use of combined continuous subcutaneous insulin infusion and blood glucose monitoring devices. There are no clinical trials that report outcomes comparing the use of a combined continuous insulin infusion and blood glucose monitoring system to the use of separate external insulin pumps and blood glucose monitoring devices. In the 510(k) approval document, the FDA determined that the combined CSII-BGM systems using wireless technology to communicate between the insulin pump and BGM are substantially equivalent to the predicate devices (i.e., separate pump and meter). There is insufficient evidence to assess the safety and efficacy of combined CSII-BGM devices (Hayes, Oct 10, 2005).

CSII-BGM Systems with Continuous Glucose Monitoring: Halvorson et al. (2007) conducted a pilot study using the Paradigm Real Time – MMT-522 to treat ten children, mean age 14.1 ± 2.6 years, with type 1 diabetes. A1C values at the end of four weeks demonstrated an improved A1C level in seven subjects. Participants did not experience severe hypoglycemia, and there were no episodes of DKA. An observational study by Mastrototaro et al. (2006) using a prototype CSII-BGM device involved 20 adult, volunteer, Medtronic employees with type 1 diabetes, five of whom dropped out of the trial. Results at the end of three months demonstrated an improvement in A1C levels. Proposed advantages of the use of these devices include: access to glucose values, trending of data, hypo- and hyperglycemic alerts with the ability to adjust insulin dosages, energy intake and activity to ward off the episodes.
There remains insufficient evidence to assess the safety and efficacy of the MiniMed Paradigm REALTime Insulin Pump and Continuous Glucose Monitoring System (Hayes, Aug 14, 2006).

Summary
External insulin pumps are designed to provide continuous subcutaneous insulin infusion (CSII) in patients with diabetes mellitus. The external insulin pump is a programmable, battery-powered mechanical syringe regulated by a miniature computer. The Diabetes Control and Complications Trial (DCCT) demonstrated that intensive insulin therapy is effective in reducing the chronic metabolic complications of diabetes and in delaying the onset and progression of secondary complications of type 1 diabetics. Evidence in the peer-reviewed literature supports the safety and efficacy of CSII in type 1 diabetics nonresponsive to insulin administration by multiple daily insulin injections (MDI) as demonstrated by persistent glycated hemoglobin level > 7.0%, recurring hyper- or hypoglycemic episodes, and wide fluctuations in blood glucose levels, dawn phenomenon and/or a history of severe glycemic excursions.

The published literature contains little information regarding the safety and efficacy of CSII in type 2 diabetics, and the benefits of intensive insulin therapy delivered via either MDI or external pump are not well established. There is no information available in the peer-reviewed literature regarding the replacement of pumps with newer models nor which features might provide additional health benefits and which are primarily for convenience or ease of use. There is insufficient evidence in the published, peerreviewed scientific literature to assess the safety and efficacy of combined CSII with continuous glucose monitoring.

Coding/Billing Information
Note: This list of codes may not be all-inclusive.

Covered when medically necessary:

CPT®* Codes Description
No specific codes

HCPCS Codes/Description
A4230 /Infusion set for external insulin pump, non-needle cannula type
A4231 /Infusion set for external insulin pump, needle type
A4232 /Syringe with needle for external insulin pump, sterile, 3cc
E0784 /External ambulatory infusion pump, insulin
S9145 /Insulin pump initiation, instruction in initial use of pump (pump not included)

I'd like to note that they make no reference to the fact that the Paradigm 522 and 722 have CGMS capability built into them...this Position Paper states you need the Guardian. Interesting. And the revised date was February of this year.

[Dewey]

Originally Posted by Funnygrl

My insurance is being silly. I asked about coverage for "continuous glucose monitors." Oh yes, we cover at 100% states them. I don't trust them though, so I keep prodding. "It's just a glucometer, right?" Uhm...wrong. So then they tell me they need the billing code. No billing code? Ok, we won't cover then. Alas, I expected this. I ask if I can pay out of pocket and be reimbursed. No go. They tell me they'll reimburse me in January if and when the codes come out, maybe. So I figure the pump add on is the cheapest way to go if I can get the pump covered, and I'll submit for reimbursement when the codes are out.

This is basically what's happening with me. My ins. wants to cover the CGMS, but needs billing codes to do so. I keep hearing they (the codes) won't be available till 2008. This is disheartening, but I'm going to go through with the purchase of one out of pocket & then submit for reimbursement. Sad all the da** hoops folks have to jump through to get something that could aid in the prevention of complications, or that could even potentially save a life.

[duck]

Can you submit for reimbursement in these circumstances?