Hello. My name is Jillian and I am a new member here. I am sorry to bother all of you but basically I’m having a rough time right now. My husband and I got married in September and he has type 1 diabetes. He was diagnosed at age 16 and since then, he’s controlled it okay but could do better. He is on insulin shots multiple times a day and checking his blood sugar many times a day also. We are both 32 years old. We have been trying to get him a Dexcom and the Omipod, as he needs both. We have been repeatedly denied by his insurance and it’s a reputable insurance company. We are really feeling very out of sorts and feel like no matter what we do, we can’t give him the quality of life he deserves and frankly I feel like a failure. Has anyone else been here? Am I doing something wrong? I’m sorry again for all of this.
TLDR… 32 year old T1D husband needs dexcom and omipod. Big bad insurance company hates us and said no unless we pay thousands a month out of pocket. Please help or share your stories.
Hi @JillianMG912. I’ve discovered the hard way that it can be challenging to navigate insurance approvals as a “civilian” - even with lots of diabetes experience. I once tried running interference between my supplier and my insurance and felt like banging my head against a wall - I finally got them on a conference call so they could communicate in technical terms and they got everything worked out.
With that in mind, have you had his endo contact the companies? Their office is - or should be - adept at navigating the requirements and providing any documentation and special authorizations that may be needed.
@JillianMG912 Hi Jillian, and welcome to the JDRF TypeOneNation Forum! Your questions are not a bother, we learn by asking questions and with diabetes learning is an on-going adventure. I’m not a licensed medical professional, so keep in mind what I offer is only based on my seven decades trying to live well with diabetes. Sixteen is a “good age” to be diagnosed with diabetes - that was my present on my 16th birthday.
Insulin infusion pumps and wearable glucose sensors are not inexpensive “little things” that insurance companies will pay for just because an insured thinks that they may be nice to have. What will make a difference with insurance coverage is that a knowledgable doctor determines " Medical Necessity", and writes a prescription accordingly. The prescribing doctor will need to provide data to substantiate the need, and an opinion that the patient will significantly benefit.
Your husband must keep in mind that “a Dexcon and the Omnipod” will not cure his diabetes; managing his autoimmune diabetes well will still take work, lots of work even with these devices.
Thank you so much for the reply. I know his doctor had contacted Dexcom and omnipod and he was denied right away. I kind of feel like he didn’t try hard enough or try other avenues but maybe I need to bring this concern up to him. Thank you for responding + Im so glad it all worked out for you eventually.
Thank you for your reply. I really appreciate it. You’re absolutely right, and hopefully his doctor can help us a bit more than he did last time. But I know you’re right about it not being a 100% “cure” by having these devices. I guess i just never realized how hard it truly was to get some kind of answers. But you guys helped a lot. Thank you truly.
Hi again @JillianMG912. I feel your frustration but please don’t feel bad about writing. There are lots of people on the forum who are willing to support and help as they can.
I was surprised at first when you said the doctor’s request was denied; but it may be that they put it in without sufficient documentation of medical necessity. Also, a particular item (or med) may not be their preferred product or device and will require will authorization over and above the initial. The insurance should have provided details about why the request was denied - hopefully additional info from your doctor will get him what he needs. Please keep us posted.
PS - you didn’t give any detail about what “doing okay” means. Some people do quite well on multiple injections - in some cases even better than on a pump. I don’t know if insurances - or your specific plan - have a medical necessity requirement but that might be something to look into especially in re the pump. I would have thought the safety features of CGMS would make them more open to coverage regardless of medical necessity. Hopefully the explanation of the denial will shed some light.
Hi Jillian - Welcome to the group, and sorry you have to join! I have one more thought to add to what has already been said here:
I don’t know how familiar you are with medical insurance plans. Yes, a letter of medical necessity will be required (or some reason these devices are needed), but they could still be expensive. There will be higher upfront costs to get the “starter kits” IE: the pump, PDM/receiver, the CGM and receiver, etc. For me, the cost was $2400.00 for my first pump with insurance. I could not afford that! But, about a year after I first looked into getting one I had to be hospitalized. The hospital bill made me reach my deductible for the first time in years. This meant I could get the pump for a lower cost! Insurance plans cover more of the cost once you have met your deductible. So, as a result, a lot of people wait till the end of the year for their insurance plan so they pay less out-of-pocket.
Another thing, have you checked which pumps and CGMs are covered by his plan? There is usually a preferred brand or brands and it is sometimes easier to get approved for these. If you haven’t already, check into this before trying to get approval.
Hi again. I just had another thought: s less expensive CGM option is the Freestyle Libre/Libre2. It’s not part of a closed loop system but it does track BGs at a fraction of the cost. I’ve used it and was actually quite impressed.
Just weighing in with support, and encouraging you to keep trying. The cynical side of me says that insurance companies sometimes — very mistakenly! — think they are saving money by denying coverage, so that is their default response.
We had to fight tooth and nail, resubmit paperwork that had already been submitted multiple times before, request reconsideration and peer review and appeal, and then appeal the denial of the appeal. All told, there were seven layers of hoops to jump through, all of which took way too much time and energy.
But in the end, we did get coverage for what the doctor had said our daughter needed all along, and you know what? Her BG is better, we’re sleeping through the night on a regular basis again, and it’s all good. So just know that it sucks, but it’s not you. Keep at it, and get your husband what he needs.
And then if you have the energy, write complaint letters to the company and to your Congressperson and to your local Attorney General and the Better Business Bureau, and see if we can convince the Lousy Insurance Companies to actually cover what they’re supposed to without us having to fight them for it!