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Question:

From Mentone, California, USA:

My daughter who has type 1 diabetes and has been on an insulin pump since August 2005. She has just been denied authorization to see her pediatric endocrinologist and team that she has seen since her diagnosis four years ago. The medical group claims that since she has no complications, so she should be followed by her Primary Care Physician (PCP). Both her PCP and I are FURIOUS, as our pediatrician has no specialized training in type 1 diabetes, much less insulin pump assistance.

I have filed an appeal with the insurance company, but wondered if you knew of any other recourse or documentation/recommendations I can cite as reason for my daughter to continue her quarterly appointments with the Loma Linda University Pediatric Diabetes Team Center.

Answer:

Your appeal of the health plan's initial utilization review decision is the appropriate step. I would make sure your PCP includes a statement supporting the referral, admitting that he cannot manage a child on an insulin, which may help, but don't count on it. Ask the PCP to contact the plan's medical director to see if he will approve the referral. Is the health plan is referring her to another endocrinologist in the plan's network? If so, you would have to show that a pediatric endocrinologist is required to provide the care required.

DSH

Additional comments from Dr. Linda DiMeglio:

I have sent a letter like this in the past to insurance companies who have tried to transfer my patients from pediatric to adult endocrinologists with success. Perhaps the endocrinologist can provide something similar. You could add a few sentences about the particular needs of children on pumps. Change the italicized words to match your needs.

"I am writing to follow up on your letter of Date to Dr. xxx I would like to appeal the decision of the insurance company to transition child's care from the Diabetes Team at xxxx to Dr. xxxx at xxxx.

I am an title in the Department of xxx, Section of Diabetology at xxxx School of Medicine. I have been caring for xxx directly since her diagnosis with diabetes in xxx.

After undergraduate training at school and medical school at the school, I did my pediatrics residency at hospital. I received my pediatric endocrine/diabetes board certification in year after completing a three-year pediatric endocrine/diabetes fellowship at hospital.

Dr. xxx trained through a residency in Pediatrics. However, he has not done a fellowship in pediatric or adult endocrinology or diabetes. Dr. xxx is not board certified in pediatric or adult endocrinology or diabetology.

Additionally, Dr. xxx does not currently work with the support of pediatric diabetes nurse practitioners or pediatric dieticians. Such personnel are an integral part of managing this chronic childhood disease. Our diabetes team staff includes xxxx pediatric diabetes nurse practitioners and xxxx pediatric diabetes dieticians. In addition to our clinical services, we provide families with 24-hour access to a diabetes-trained nurse practitioners, pediatric endocrine fellows, and board-certified pediatric endocrinologists for any emergent questions or concerns.

xxx continues to need the specialized care that only a certified pediatric endocrinologist/diabetologist can provide. While there may be reasons to transfer care between providers when equivalent services are available, in the case of type 1diabetes, xxx currently is able to provide services that are of "a unique nature" and should "preclude transition to another provider."

Thank you for your attention to this matter. Please feel free to contact me with any questions. I look forward to hearing from you."

LAD

Additional comments from Dr. Larry Deeb:

No pediatrician in his right mind wants a kid with type 1 diabetes when there is a pediatric endocrinologist around; it's a liability issue. When an HMO here said that "all the pediatricians refused to take a child with type 1 into the practice and even threatened to resign from the HMO; the HMO relented." Even a huge HMO only has a few children with diabetes; it's not worth the trouble, if the pediatricians make a stink

LD

Additional comments from Dr. Stuart Brink:

I think this is disgusting and would suggest that you get a lawyer immediately. Contact the American Diabetes Association since they have lawyers familiar with such problems.

SB

DTQ-20060202162733
Original posting 6 Feb 2006
Posted to Insurance/Costs

  
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Last Updated: Tuesday April 06, 2010 15:10:06
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