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Question:

From Lexington, Kentucky, USA:

I am writing for advice on how to approach my insurance company with an appeal for their denial of coverage for the new OmniPod system for insulin delivery. They first denied coverage because my A1c was not above 7. After a letter from my endocrinologist explaining that I have hypoglycemic unawareness and frequent lows, they then denied again for basically the same reasons with other language indicating that there was no research that this type of system was better than a regular insulin pump or MDI therapy. I tried a pump in the past and was not happy with using it and had more highs than I ever had with injections. I've been a type 1 diabetic for 36 years and have noticed that it seems that only diabetics who cannot maintain good control and end up with complications are ever considered for new therapies or devices while those who work hard at staying healthy are punished by being relegated to older treatments. How can I convince my insurance carrier that the OmniPod would help me stay healthy and would help me avoid frequent lows?

Answer:

I recommend that you contact the manufacturer of this equipment and ask them to provide you with any research or data published in a peer reviewed article as evidence of the benefit you would receive from treatment using this device.

Many health plans have established arrangements with preferred pharmaceutical and DME manufacturers; these are called exclusive formularies. Generally, insureds are required to pay higher copays or cover the cost of items and medicines/strips not on the plan's formulary. As you are finding, your health plan contract probably provides for higher copayments or coinsurance requirements for drugs and items not on their formulary.

You are entitled to file a written appeal to the decision of the plan concerning the use of a particular device. This appeal should contain documentation from your physician of the medical necessity of the use of that brand of equipment. You must follow the timelines and requirements established by the plan to proceed with your appeal.

Many health plans justify their coverage decisions on the lack of medical evidence or research to support a claim that one device or therapy would benefit over another. I recommend that you survey the medical literature for such evidence of the efficacy of this treatment.

Please note, I am not a medical professional and thus cannot speak to the relative clinical advantage of one medical device or treatment modality compared to another.

DSH

DTQ-20070507083904
Original posting 12 May 2007
Posted to Insurance/Costs

  
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Last Updated: Tuesday April 06, 2010 15:10:12
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