Fighting For My Life

Time for an update on my campaign to become an insulin pumper.  Ouch. Painful experience dealing with Blue Shield, so far.  Enormous amount of time spent explaining to perfect strangers — from the HR reps at my husband’s company to various “reimbursement managers” to a parade of officials at Blue Shield (forthwith to be referred to as ‘BS’) itself — why I ought to get medical coverage for a life-sustaining device that my doctors have been recommending for nearly four years.  Very humbling.

Kungfu_1 “You see, since the day I was diagnosed, my doctors have been telling me that I’d be the perfect candidate for the pump. I’d get improved control of my diabetes, and therefore achieve better health outcomes in the long run.  But it was ME who resisted. I didn’t want some contraption hanging off my body.  But now there’s a new, wireless system that will help me control my diabetes without the tubing…”

My God, it’s not as if this were a cosmetic request!  Do you think I’d wear a Pod full of liquid attached to my Bod if I didn’t absolutely have to?  It’s not like I’m asking for a nose job here.

Some time back in November I got my first rejection, supposedly on the basis that “continuous glucose monitoring is still experimental therapy.”  WtF?  Do they not even know the difference between a glucose monitor and an insulin pump over there?  Then I figured it was a simple mixup with the request for reimbursement that Dexcom (makers of the wireless CGM system I’m now using only occasionally) had placed on my behalf months ago; I had long since given up on seeing any of that money again.

Got my endo to contact the Medical Reviewer over at BS to clear that up, but my doctor was told that wasn’t the real reason for rejection at all: it was a cost-effectiveness issue, after all. Hmm, pump to prevent outrageously expensive complications of diabetes too expensive for them in the short-term?  We’ve all heard that retarded story before.

Despite the fact that at least a dozen other patients in California have managed to secure BS coverage for the OmniPod, the reviewer assigned to my case was (is?) still under the false impression that traditional pumps are more cost-effective for the health plan.  Insulet (makers of the OP) assure me that this is hogwash.

Nearly jumped out of my skin on Friday when I received a BS letter stating that I’d been approved for a “standard insulin pump.”  But wait just a minute… what do they mean by “standard”??  Surely the careful employment of that term was meant to exclude the OmniPod…?

Seems so indeed.  The Insulet liaison assures me that this letter — inexplicably — is probably meant to uphold the original denial.  Aargh!!

OK, yes. I could purchase the unit on my own out of pocket.  But my deep and wide experience haggling with health insurance providers tells me that once you’ve actually paid for something yourself, trying to get them to pay you back for it is like… well… pulling teeth, without anesthesia, over a period of several years. (I was still trying to reclaim the money for my first C-section after I’d recovered from my second one).

Not only that, but I’ve talked it over with my husband, and we agree: it might be all right for us to put up our own money to buy the OmniPod system, if it’s still considered so new as to be semi-experimental.  BUT we need some assurance that the insulin pods will be covered going forward, as that will become my life-sustaining insulin source!  Whether the insurance pays for insulin in cartridges that fit into an injection pen, or in pods that pump the stuff into me directly through my skin shouldn’t really be too much skin off their nose, ay?

** SIGH **  (That was a loud one)  I once thought I might have my OmniPod by Christmas.  Then I reset expectations to Valentine’s Day. Now it looks like President’s Day will be a stretch.  Passover might be nice symbolism.  Cross your pocked fingers for me, will you all?

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22 Responses

  1. Big_DaveT
    Big_DaveT January 15, 2007 at 9:28 am | | Reply

    My wife deals with BC/BS all the time in her job as a customer service representative for a physician practice plan. Persistence sometimes pays off with them, but if this device is considered “investigational”, then you will probably need as much luck as persistence.

    Not sure what type of BC/BS you have, but plans differ from employer to employer based upon what type of insurance plan was purchased. You might want to check with a personnel type person at work to see if they can help.

  2. AmyT
    AmyT January 15, 2007 at 9:57 am | | Reply

    Thanks, Dave, but this device is NOT investigational. That’s the point.

  3. Adam Kaye
    Adam Kaye January 15, 2007 at 10:34 am | | Reply

    Amy,
    I was fortunate enough not to have to put up with much resistance starting the Omnipod (I’m on the Yale University health plan for students). However, I remember working out the math on my own, how much more the Omnipod was over a four year span than a “traditional pump,” and it wasn’t that much. You may want to figure it out and, if it’s not too much use it in your argument with BS. The numbers I used for the Omnipod: cost of the pod=$800 (one time fee), about $325 per month for pods. Cost of “traditional” pump for 4 years is about $6000, then you have to figure out how much the insertion sets are per month and add it on.

  4. Carol
    Carol January 15, 2007 at 10:58 am | | Reply

    Amy, I really sympathize with your frustration. AFTER insurance had approved and paid the claim for my current pump (directly to the pump co), they then denied it and began harassing me to pay them back. It was clearly covered, but after a year of arguing with them, I had to go to the State Ins. Board to get it resolved. So Adam’s suggestion is good, but he’s making the assumption that the health plan will listen to reason. BIG assumption. I’m betting your tenacity will pay off though.

  5. shawn
    shawn January 15, 2007 at 11:06 am | | Reply

    i had to battle my old health insurer last year to get the omni pod approved
    they called it out of network and after 3 months approved only 30% of the cost
    then in october, when i knew i was switching to cigna in 2007 i found out that cigna flat out will not cover an omni pod-considers it experimental
    so i shop my butt off for decent affordable coverage, and wind up with horizon bc/bs in nj-which is costing me 2k extra per year

    in november when i realized the omni pod was not working well for me (trust me it is experimental-wait for 2nd gen, please)
    my old carrier approved 100% of my cozmo costs 24 hours after the rep domo’d it for me and we faxed in req’s
    but bc/bs has played a game;new jersey has a mandate so insurers cannot limit tthe coverage of “diabetic supplies”
    but bc/bs catagorizes all the disposable pump supplies as durable medical goods, even though they are syringes, dressings and tubing
    so my low cap on durables will be spent in 6 months
    i may set the record for most days without an infusion site change, because jst like those pods, these costs add up

  6. Lori
    Lori January 15, 2007 at 11:31 am | | Reply

    I am with Blue Cross/ Blue Shield of North Carolina. I decided that I wanted an Omni Pod when it was time to get my MiniMed fixed (for the third time). I still had about 2 years of my warranty left and they still covered the Omni Pod at 80%. I was very surprised. I ended up having to order the Omni Pod and then wait and see if the insurance would cover it. Omni Pod does give a 30 day money back guarantee so I used that until I found out if they would cover either the Pod or the supplies. Omni Pod did not make me pay until the insurance company reached their decision.
    I think it also helps if you provide a letter from your doctor on why the Omni Pod is the best it for you. This is especially true if you can explain how other pumps can affect your career. I think it helped my case that I am a teacher and the tubing can sometimes get caught on desks or make some parents a little unsure about leaving their kids with me. Now (without the tubes) they have no idea I am diabetic (until I want them to know). I love the Omni Pod system! I don’t know if it helps but that was my experience.

    1. Margie
      Margie November 7, 2011 at 4:13 am | | Reply

      Hi Lori,
      I saw your post. My son is at college at UNC Chapel Hill. He didn’t realize he was out of pods when his last pod expired. It will take a day for him to receive a new pod. He has a box of pods at home but we live in NJ. He has been doing extremely well with the omni pod and is scared to use Novolog. Where do you live? Would you be willing to lend him a pod and we will send you a replacement? Please call me if you have any suggestions. My son has a car and is willing to drive to get a new pod. Thank you so much!
      Margie 201-486-2186

  7. Bernard Farrell
    Bernard Farrell January 15, 2007 at 12:56 pm | | Reply

    Amy

    I could tell you some long tales about battles with the Blues for many years.

    Luckily I live in Massachusetts and several years ago (maybe 5 now) we managed to get legislation passed to mandate coverage for diabetes supplies.

    That in itself is another long story involving several years of organizing “Diabetes Day on the Hill” meetings to talk with legislators, who didn’t really listen until the year a certain Miss World turned up to demonstrate her support for the cause. Then we had legislators and insurance company representatives overflowing the place.

    And within a year after that we had our legislation.

    Since then I’ve probably changed insurance companies a few times and for the most part it is without too much problems in terms of supplies and equipment.

  8. Annie
    Annie January 15, 2007 at 1:24 pm | | Reply

    BC/BS—is it Blue Shield or just plain BS?? Interesting coincidence with the initials. Good luck with Cigna. My experience with them has been very negative—they reject payment for diabetic testing supplies, they told me using syringes was more cost effective than pens (luxury item), they rejected my Omnipod application out right (as you have already discovered.) They actually had the nerve to tell me that no one in the CT jurisdiction had even attended an informational session, inservice, etc, on the Omnipod–they simply weren’t covering it because it was a luxury item!! LUXURY ITEM!!! Are you kidding me???? I finally decided to get the Minimed and it has been fine, except for that wonderful tube and trying to remember that it is attached when I need to use the bathroom–had a few close calls almost yanking the thing out. My friends at Cigna then told me they would only send me a finite amount of insertion supplies–regardless of how my endo ordered them–and that if I ran out—tough beans. So, it continues to be a fight every day to stay healthy. Somehow, the geniuses at the insurance companies can only see short term and refuse to acknowledge that a diabetic who is compliant and able to keep a decent A1C will actually cost them less in the long run. It seems pretty basic to me….

  9. Becky
    Becky January 15, 2007 at 1:36 pm | | Reply

    Ok, spill the beans Amy! How on Earth are you getting an Omnipod when they aren’t selling beyond the East Coast yet?

    Sorry for the hassle. There is a great website called http://www.patientadvocate.org that can help you with an appeal.

    Good luck!

  10. Carrie
    Carrie January 15, 2007 at 3:05 pm | | Reply

    yeah! How did you get it? Is it now available in California? I heard in November that it was only on the East coast, and I signed up to get informational e-letters but so far have heard nothing. I am getting a Cozmo instead, but hope someday to try the omni. good luck!

  11. DaveH
    DaveH January 15, 2007 at 5:57 pm | | Reply

    My wife and I had a similar experience with Cigna getting her approved for a MiniMed. They would approve some other brand of pump, but not Medtronics.

    We finally got results by using the advocate for my health plan. After explaining to the advocate, a 6 month battle turned into coverage in a few days.

  12. Michael Park
    Michael Park January 15, 2007 at 6:27 pm | | Reply

    Hmm, I’m still not sold on the pump being worth the seemingly billion dollars for a pump, which would be completely out of my poor student pockets.
    I actually brought the issue up with my Diabetes Educator today, and it seems that the only thing interfering with having better control is CONSISTANCY.
    She wants me to be as consistant as possible with my multiple daily injections and see how much magical improvement there will be.
    Nevertheless, I hope my finances eventually get better, it would be nice to not have to take a billion needles a day…

  13. difficultpt
    difficultpt January 15, 2007 at 9:00 pm | | Reply

    I came over here to tag you (I know how you love memes), but now I’m just pissed off at the insurance companies. I’ve had BCBS in the past myself. Oh lordy, I feel an insurance rant coming on over at my blog . . .

  14. JasonJayhawk
    JasonJayhawk January 15, 2007 at 10:14 pm | | Reply

    As DaveH reports with Cigna, insurance companies have agreements with specific pumps — nicknamed “workhorse pumps” — because all they do is pump, but with very little intelligence. The D-Tron and H-Tron pumps, and now the Spirit pump, are all workhorse pumps. They offer minimal functionality, with a 4-year time limit (yes, even the Spirit pump becomes disabled after its 4 year timer counts down to 0 seconds, making it a worthless piece of junk). Insurance companies know that the average employee stays with a company for about 6.5 years, and they just don’t see the savings for healthcare improvement.

    Amy, you have one simple solution. Remind them the cost of two hypoglycemic events in the ER room. Or DKA from lack of insulin. These events will easily surpass the cost of a “non-standard” pump.

    There was an insurance company (I think Cigna, but could be wrong) actually got in trouble a few years ago for setting up a fake pump company that made the doctor think they were prescribing the patient the pump of choice (actually, a cheaper, underpowered pump). Watch out for their tricks.

    Unfortunately, Omnipod is not doing well with the rollout. It will be hard convince them of investing in a product that might not be around in 2 years. :-(

  15. Jules
    Jules January 16, 2007 at 1:16 pm | | Reply

    I just finished up a saline start of the omni pod. I was very impressed with it. I was going to try the other pumps but decided that they couldn’t be better than the omni pod. The PDA was very intuitive and I tried the pod in multiple locations all of which worked out just fine. It’s a little thicker than I would like but not having tubing is a big plus. Last month I attended a pump class and everyone there wanted to start with the omni pod. Seems like those new to pumping are the ones see the big benefit. My insurance company is Aetna and they have an agreement with onmi pod so the insurance coverage is looking sweet. Good luck to all.

  16. Kirsten
    Kirsten January 26, 2007 at 6:30 am | | Reply

    My 3 year old has been on the Omnipod for 7 months. We have Harvard Pilgrim HMO and everything is being covered 100% (no hassles). We love the omnipod!

  17. Andrea Dickson
    Andrea Dickson January 26, 2007 at 11:36 am | | Reply

    Ah, insurance companies. I have a t-shirt at home that reads “I love Regence Insurance!”. My favorite part about insurance companies is their “waiting period” following a period of being uninsured. I was uninsured for a year while working as a contractor, and paid all of my expenses out of pocket. Nearly six months after becoming insured again, Regence still won’t cover my diabetes needs.

    Is that sort of counter-intuitive to anyone else? You HAVEN’T been insured, so we’ll make sure you still AREN’T for another 9 months?

    I hadn’t heard of the Omnipod, but I have a feeling my doctor might put me on the regular ol’ pump soon enough.

  18. Karen
    Karen November 21, 2007 at 3:45 pm | | Reply

    I wanted the omni pod so bad. It took 8 months for Insulet to get themselves together. It wasn’t the insurance company at all. I had Blue Cross/Blue Shield. They weren’t the problem. It was the morons at Insulet. Si I finally got the omni pod and sent it back after 2 weeks. I hated it. The pods stick out under your clothes and it looks like a big buldge. Gross…. The control center. so to speak is just something else to carry around in your purse or for a man, something to put in the other pants pocket beside the wallet. When it alarm in the middle of the night, you have to get up and find the other piece to see what the problem is. What a pain in the, well you know what.
    Don’t get the pod. I have had an H Tron plus for 10 years. They replace them every 2 years and give a great credit for the old ones. My insurance pays every penny. I have paid nothing except for the infusion sets, cartridges, etc. After all the hoopla, the omni pod isn’t worth the trouble and expense. DON”T GET IT…..

  19. cate
    cate January 3, 2008 at 4:07 pm | | Reply

    i’ve been a pod user for a year, pump user for 8, i think. anyway, i had HIP when i started on the pod with a minimed that was working just fine. my doctors office said it was medically necessary and it was approved in 4 weeks with an extra annual copay of $100 which i had to pay with minimed anyway. i received 2 training sessions with the diabetic educator as well as several followup calls from omnipod. also i saw it posted that insulin pump therapy is investigational. it is not. it is indicated for use of all diabetics when the doctor says it is medically necessary.

  20. sharla
    sharla May 3, 2008 at 8:44 pm | | Reply

    I have a very limited Unicare policy, and it does cover my insulin, test strips, syringes, and humalog pens (up to a total ANNUAL output on their part of $500), but says that there is NO durable medical coverage. I can not get a pump-period. Good thing I don’t need a pacemaker. For those of you who do have pump coverage, but cannot get the latest and greatest, please consider counting the blessings you do have.

  21. JJ
    JJ September 1, 2008 at 6:08 pm | | Reply

    Hi, has anyone received coverage for a pump from Blue Cross Blue Shield of Illinois? I called yesterday and was shocked to hear that they do not cover any diabetic supplies for the pump. ONLY the insulin and syringes. I am working with my physician and pump rep, just wondering if anyone else w/ this insurance has heard this.

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