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When the Insurance Company Denies Coverage for Your Pump

Cindy Freudenthal, RN, BSN, CDE

Feb 1, 2004

How to Change “No” to “Yes”

You’ve gone through all the diabetes education classes. The insurance company pays for them.

You see your physician and necessary specialists as ordered. The insurance company pays.

You test your blood glucose four or more times a day and take several injections every day. The insurance company pays for the strips, syringes and insulin.

You decide to get an insulin pump to improve your control and prevent serious complications. The insurance company denies it.

Don’t Accept “No”

Always remember that there are ways to change “no” to “yes.” According to Mike Doredant, regional director at pump manufacturer DANADiabecare USA, the main reason that insurance companies deny coverage for insulin pumps is lack of information. Begin by determining whether your insurance company actually covers insulin pumps in any circumstances. Read the Explanation of Benefits (EOB), the printed form you received from your insurance company that explains what was paid, what wasn’t paid, and the reasons for nonpayment. Contact your insurer if you need more information or clarification.

Be sure all the “blanks” are filled in. Copy all documentation such as blood glucose records and physician notes, and check that the correct diagnosis code is printed on the claim form.

Some companies require precertification for medical equipment or procedures. Although this does not guarantee payment for your pump, it does give you a “green light” of sorts to continue.

Appeal and Ask Questions

If the answer is still “no,” you can appeal the decision.

Contact your insurance company to find out the steps involved in the appeals process. Ask about special forms, required documentation and the timeframe in which the appeal must be completed.

Jeff Ruiz, diabetes management consultant with Medtronic MiniMed, advises asking plenty of questions, being persistent about regular follow-up with the insurance company, and getting everyone involved, including the manufacturer’s insurance specialist.

A letter from your physician explaining why you need an insulin pump would be also beneficial.

Document everything!

Even if the claim is denied again, there may still be hope. For example, in some states, such as Louisiana, you can request an independent appeal. In this process, someone outside of the insurance company reviews your claim and renders a decision. Call your benefits manager or your own state’s insurance commissioner for details.

The harder you work, the more likely it is that your pump will be approved.

Categories: Blood Glucose, Diabetes, Diabetes, Health Insurance, Insulin, Insulin Pumps, Syringes

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