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The Question
Tue Feb 07 04:49:43 EST 2012

medicare refuses to pay for infusion sets because my c-peotide is.90 rather than min. of .88. what can i do?
Asked By: rileyv  

Background Info Hide
I was diagnosed with type 2 twenty years ago.my doctor tells me that weight an exercise currently have little effect on my desease. I eat as little as possible and execise three to four days a week. 12to16 miles treadmill and 3 to six hrs on weights and weight machines. I had severe reaction to insulin. both injection site, hives, and facial swelling. I have been on a pump for three years and currently take 16.8 units of humulin R daily with metformin and januvia and i am in good control. I presently can take no other insulin. When off of insulin i begin to lose muscle mass and weight. and though I eat very little my blood sugars go into th 500s. I was forced to take medicare as my primary in January, now my secondary(former primary) won't cover my infussion sets if they are denied by medicare. I have thirty days of supplies left. Any one have simular problems? They run around $400 a month.
Diabetes Profile Hide
n/a
Expert Answers (2)
2012-02-08 22:10:30.0

. . . . and after you do all that Rita suggested, check with your local diabetes educators or health clinics. Often those who are stopping pump therapy, or have lost a loved one who was on pump therapy will donate unused supplies. Also, with your C-peptide test being so close, you might want to try having it run again when you have been fasting for a good long while and eating as little carb as possible the day before. The less insulin your body needs to make, the lower the C-peptide is likely to be.
Answered By: Anne Carroll
Accreditations: RN, CDE
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2012-02-07 20:02:16.0

Hello rileyv
Thank you for bringing your question to dLife.

You state that you have severe reactions to insulin yet you are on Humulin R via a pump without problem. I do not think you have reactions to that particular insulin. Maybe you have a reaction to other insulins or other carriers in insulins in vials. Humulin Regular is certainly available in vial. So, have you tried Humulin R via vial and had bad reactions?

As per Medicare refusing to cover the infusion pumps, is this continuation of care? It seems you have successfully been on this treatment for three years. Are you new to Medicare? Were they covering this treatment before?

If Medicare is refusing this treatment, you must do this:

Have the ordering provider submit a letter of medical necessity explaining in detail why you need this therapy. What has been tried in the past and failed. What reactions you have had. There is always an appeal process if they refuse. Follow through on the appeal process. If you doctor is not willing to do all this for you, find a new doctor. I suggest seeing an endocrinologist or a diabetic specialist for a full evaluation. Find a par provider and and get seen as soon as possible.

Answered By: Rita Juray
Accreditations: RN, MLT-ASCP, CCM, CDE
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Community Answers (4)
2013-02-10 02:29:36.0

I have Tpe 1 Diabetes. I have AARP United Healthcare Medicare Advantage. They pay 80% of the Insulin Pump and Continue Glucose Monitor Supply costs. Your Endocriniologist may need to supply 6 weeks to 2 months of your glucose readings before and 2 hour after each meal to build the medical case of necessity for you to have Insulin Pump therapy and/or Continuous Glucose Monitoring therapy. I wear an Animas One Touch Ping Insulin Pump and a Dexcom Seven Plus Continuous Glucose Monitor. Before Medicare, my private insurance paid 100%. So even the 20% on my lower fixed income hurts. Best wishes.
Answered By: theresamd

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2013-02-10 02:29:35.0

I have Tpe 1 Diabetes. I have AARP United Healthcare Medicare Advantage. They pay 80% of the Insulin Pump and Continue Glucose Monitor Supply costs. Your Endocriniologist may need to supply 6 weeks to 2 months of your glucose readings before and 2 hour after each meal to build the medical case of necessity for you to have Insulin Pump therapy and/or Continuous Glucose Monitoring therapy. I wear an Animas One Touch Ping Insulin Pump and a Dexcom Seven Plus Continuous Glucose Monitor. Before Medicare, my private insurance paid 100%. So even the 20% on my lower fixed income hurts. Best wishes.
Answered By: theresamd

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2013-02-08 21:23:12.0

Hi. I just went through denial of my prescription for Byetta when I became Medicare eligible. Through a prompt and diligent response by my health care providers, it has been approved. Rita's advice to get a letter of medical necessity is spot on. It was explained to me that because I was prescribed the Byetta prior to becoming eligible for Medicare, I had not fulfilled the steps required by Medicare to be prescribed Byetta. Your situation sounds very similiar. Of course the Part D provider you have also has a bearing on how and what is paid for.
Answered By: don2451

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2013-02-08 11:25:44.0

Is your former insurance considered a medicare advantage plan?. If not it knows your are on medicare. Are you still covered under your old plan? You have a certain amount of time to get a new plan. They may think you have a new plan therefore they don't have to cover you. Talk to an insurance agent and get the supplemental plans for medicare. Medicare needs to hear from them before it will pay anything.
Answered By: aremson

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*** All information contained on dLife.com is intended for informational and educational purposes only. Our Expert Q&A is not intended to be a replacement or substitute for consultation with a qualified medical professional or for professional medical advice related to diabetes or another medical condition. Please contact your physician or medical professional with any questions and concerns about your medical condition.

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