Cigna Healthcare, one of the largest healthcare insurers worldwide offering coverage to millions of people, unveiled their revised medical policy for external insulin pumps on Monday (15 March 2010). It was not a news event, but it should be — roughly 250,000 people utilize pump therapy for tighter control and greater flexibility. Nick Jonas has a pump. Many superstar athletes utilize insulin pump therapy such as recent Olympic competitor, Kris Freeman and Chicago Bears quarterback, Jay Cutler . In fact, CSII (Continuous Subcutaneous Insulin Infusion) is for some the coolest, most effective way to treat insulin dependent diabetes. And apparently, insulin pumps are also a becoming a viable option for people with insulin dependent type 2 diabetes – according to a 2009 position statement by the American Association Of Diabetes Educators (AADE).
Many type 1 patients who would greatly benefit an insulin pump continue to utilize Multiple Daily Injections (MDI) as their treatment regimen for a variety of factors including fear, cost and accessibility. I recently spoke to an individual who wondered what they needed to do to “get” one. He felt behind the eight ball, and had no idea how to justify or fund insulin pump therapy. Moreover, many people with insulin dependent diabetes may not understand how to discuss it with their healthcare provider (important first step) or what considerations a doctor must make in prescribing one. There are in fact a few matters that require attention when considering insulin pump therapy and it may take time. There is a process and a part of that process is figuring out coverage.
To Cover or Not to Cover
The difference in coverage can be measured by where you live. In 2008, the National Institutes of Health and Clinical Evidence or NICE (the public health guidance board in the UK under the National Health Service – NHS) made it binding that all children in the UK under the age of 12 and over one year old were automatically given an option for the insulin pump regardless of previous treatment. In fact, NICE even went so far to say that if a doctor recommended the pump for any patient (regardless of age), under no circumstances could a local health board deny or wait-list that patient. In the UK, if your doctor has prescribed pump therapy – the pump and ALL the monthly supplies are covered. That’s good news for people who reside in the United Kingdom. This doesn’t mean that the UK has a perfect system but what it does reflect is a national healthcare consensus putting the patient first. (Insulin pumps are also covered in Sweden and many other European countries.)
In the United States, the financial burden is on the patient to prove it is medically necessary, that is, IF you are covered by health insurance. Without healthcare coverage of any kind, patients need to self-cover. This would mean an immediate outlay of roughly $6000-10000 US for the pump, and monthly costs hovering around $350-500 depending on the model, and other types of technology a patient might use to support the pump ( CGMS , software, kits, accessories.) But before you start packing up your bags and buying a ticket bound for London – there is a basic format to follow for those of you who are covered privately. For patients who are not covered – Islets of Hope is an organization who supports people with diabetes and they have a webpage that lists a multitude of resources for assistance. Many pump companies also offer financial aid.
Self-evaluation. Educate yourself about pump therapy and its benefits. Self-assess your current treatment plan and the reasons why you want to switch. Make a list of all the questions you have and why you believe the insulin pump might be a good option. Now you have something to take to your doctor and discuss.
Are you currently under the care of a diabetes healthcare team who supports patients on insulin pump therapy? If not, find one. Speak to your endocrinologist or diabetologist (and if you don’t have an endocrinologist caring for your health – get a referral now and get started) because they are the only ones who can safely prescribe the pump for you. Make sure your provider has a support staff, time to oversee the transition and will offer support for you and the pump therapy in the months ahead. Conversely, the doctor will need to assess your diabetes health and your healthcare management skills. The insulin pump can be a very difficult tool to manage and the first three months are the most intense. The bottom line – your doctor will be evaluating if this is the best mode of treatment for you because he/she wants you to succeed.
Here are the types of things your doctor will assess:
Has this patient made efforts to manage diabetes to the best of their ability so far? Blood sugar monitoring? Records? Insulin regimen?
Is the current regimen succeeding?
Will the patient be capable of managing the extra work it takes to utilize insulin therapy?
Are there any other problems (personal, health, other) that might prevent success?
It is important to keep in mind that your doctor and you are discussing options – rather than perceiving the meeting as a judgment session. If a patient isn’t achieving success with MDI but making an effort – most doctors will support the switch. (This includes pediatric care too).
A formal letter stating the medical necessity of the insulin pump must be written on behalf of the patient. Often the healthcare provider will manage this part of the process with your insurance company. If not, file the doctor’s letter with the most appropriate decision maker at your insurance company and treat the letter as if it were your (or your child’s) college application. Confirm receipt and follow up! Don’t give up. Ever. There are usually pitfalls and problems. The key is to support the medical need with documentation. Persistence is the only way to success, along with a diabetes healthcare team that has your best interests at heart.
Generally insurance companies see it this way:
Insulin pump therapy is indicated for:
Patients who are unable to achieve acceptable control using a regimen of multiple daily injections
Patients with histories of frequent hypoglycemia and/or hypoglycemia unawareness
Patients who are pregnant
Patients with extreme insulin sensitivity (pump therapy facilitates better precision than subcutaneous injections)
Patients with a history of dawn phenomenon (these patients can program a higher basal rate for the early morning hours to counteract the rise in blood glucose concentration)
Patients who require more intensive diabetes management because of complications including neuropathy, nephropathy, and retinopathy
Patients taking multiple daily injections who have demonstrated willingness and ability to comply with prescribed diabetes self-care behavior including frequent glucose monitoring, carbohydrate counting, and insulin adjustment