As of 1/1/13 I am on a new health insurance plan with United Health Care. My wife’s employer made the change from Humana to United Health Care, which brings along with it a whole new adventure in getting my *betes stuff covered.
I’ve discovered that
And I haven’t even asked if they’ll give me any grief when I place my first OmniPod supply order. Also I was hoping to get a CGMS in 2013, which I’m sure will only lead to more denials and wasted hours on the phone.
Basically I’m a big complainer, but I just want to live my life as a Person with Diabetes (PWD) and achieve the best health possible, and insurance often times gets in the way of that. I know I should be grateful I have medical insurance at all, but geez, it sure is a lot of work.
So I am a Type 1 Diabetic and have been on an insulin pump of one kind or another since the early 2000s. I moved from TN to TX in 2011 and went from one insurance (Blue Cross) to COBRA to Humana when I got married and joined my wife’s company’s medical group policy. My new insurance (Humana) has been covering my insulin, test strips and other Rxes without an issue. In March of this year I switched from a Medtronic pump to the OmniPod. I love the OmniPod and have had a pretty great experience with it. That is until I tried to get Humana to pay for the pump supplies. Note I say pump supplies, not an insulin pump. I outright bought the Personal Diabetes Manager (PDM) through a special program Insulet (the maker of the OmniPod) had going on. Insulet then billed my insurance for the supplies (the pods) and through that first order I would have met my Humana personal deductible for the year, then giving me 100% coverage of supplies for the remainder of the calendar year. Or so I thought. Turns out Humana thinks otherwise and has denied my claim based on lack of medical necessity.
Really Humana? I’m a diabetic. It is medically necessary. Yes, insulin pump supplies do cost more than straight up needles, but you are going to claim there is no medical necessity for the life sustaining support provided by an insulin pump? I had Insulet reach out on my behalf to Humana and they reviewed the claim and “maintained their decision”. And here’s the best part. In June of this year Insulet processed my first supply re-order and billed it to Humana. Humana approved the claim and paid a portion of it to Insulet (if they had approved the first claim the order would have not cost me anything because I would have met my deductible). Now because of Insulet and me trying to get them to approve the first claim not only have they maintained their NO answer to the first claim, but they’re now claiming the second order was processed in error and are retroactively denying the second claim in June. Yeah, I’m none too pleased.
I’ve now filed a written appeal that I had to mail to their P.O. Box (thus not allowing me to overnight it via UPS/Fedex) and will wait the ~ 60 days for them to review the decision again and potentially approve it. There in lies my problem since I only have ~ 15 days left of supplies. My plan is to call Humana until they are tired of me and ask them to expedite the process on medical grounds. I thought I would even post my appeal letter (minus the sensitive info) here too in case someone ever needs a template of how to write it.  Although, I wouldn’t say it works as obviously I haven’t got a decision in the affirmative yet.
Hopefully Humana will see the error of their ways and use some common sense and approve the claims. I mean they could have at least come up with a creative denial reason besides “lack of medical necessity”. Geez
My Humana Appeal Letter - http://file.davediabet.es/humana_appeal_redacted.pdf
 I too used a template I found by Googling “sample of insurance appeal letter” and used this sample letter - http://sebasticookvalleyhealth.org/billing-help.aspx?id=18374
Last 3 months of my glucose readings in pie chart form. Note to self: I started OmniPod 6 months before this post in March 2012.
Test strips are a very important part of a person with diabetes’ (PWD) life. Personally I have used test strips from many of the major manufacturers of blood glucose meters and test strips like Lifescan’s OneTouch, Bayer’s Contour, Roche Accu-check’s Compact Plus strip drums, and now I use Abbott Diabetes Care FreeStyle test strips. However, according to Insulet, the maker of the OmniPod, I am supposed to only use FreeStyle strips, but not FreeStyle Lite. Despite the fact that the strips look exactly the same. Confused? I sure was. I have been told by someone who knows about OmniPod and the different test strips that Abbott makes, that the FreeStyle Lite strips that have a code number on the vials are OK to use inside my OmniPod Personal Diabetes Manager (PDM). This is my experience, and it would be nice if Insulet and Abbott would officially announce the fact that the FreeStyle Lite strips work in the PDM. It would certainly make me feel better. I’m still going to use my FreeStyle Lite strips and until someone who I know and trust with my Diabetes care tells me otherwise, I’ll continue to do so.
I do hope that the rumor that Insulet is going to release a new version of their PDM that will use Lifescan’s OneTouch strips will come true as I do get the best co-pay price from my insurance provider on their test strips.