Since diabetes is such an individualized experience, it’s important for the people living with diabetes to be involved in making the choices for their diabetes self-management. One of the benefits of having the healthcare system that we have in the United States is having options to choose from with regards to healthcare.
But who actually decides what tools or medications you have available to you as a person with diabetes? Your insurance. Most private insurance companies will cover what the Centers for Medicare & Medicaid Services (CMS) cover.1 Essentially, private coverage depends on CMS coverage.
Diabetes researchers recently looked at CMS’s requirements for patients with diabetes to be covered for an insulin pump.1 They outlined the staggering costs of short-term and long-term complications to our health care system, and discussed how diabetes technologies have been proven repeatedly to help improve outcomes and decrease costs for people with type 1 and type 2 diabetes.1
One of the authors, pediatric endocrinologist Dr. Gregory Forlenza from the Barbara Davis Center in Colorado states, “The current Medicare guidelines for insulin pump coverage, which also trickle down to Medicaid and private insurance coverages, do not match the state of modern diabetes technology usage. To address this, our group of experts reviewed each criterion and recommended up-to-date guidelines to better facilitate access and choice for people with diabetes.”
One of the requirements of CMS is to measure a c-peptide level as a criteria for use for insulin pumps.1 This would exclude people who have type 2 who are still making small levels of insulin, despite being insulin-dependent. It also requires costly, time consuming lab work for people with long-standing insulin dependent diabetes with no evidence as being necessary.1 See more on c-peptide here.
Another contradictory criterion that CMS requires is that people check their blood glucose four times a day, despite Medicare only covering three test strips a day.1 The work-around is to either pay out-of-pocket for the additional test strips (typically $1/test strip) or have the health care provider complete extensive documentation, which is costly and time-consuming.1
The article strongly recommends that both CMS and health care providers do their best to reduce the barriers to help people with diabetes succeed with diabetes self-management, including making access to the latest tools and technologies easier.1 Especially given most people with diabetes in the U.S. are not meeting the targets outlined by the American Diabetes Association for decreasing risks of complications.2
Dr. Forlenza and the team of researchers are hoping that the article will encourage less restrictive processes and improve access to better care for all people with diabetes. Here’s hoping they will hear what the knowledgeable group has to say and make changes to their guidelines.
- Lost in Translation: A Disconnect Between the Science and Medicare Coverage Criteria for Continuous Subcutaneous Insulin Infusion (Diabetes Technology Therapeutics, June 17, 2021)
- State of Type 1 Diabetes Management and Outcomes from the T1D Exchange 2016-2018
Written and clinically reviewed by Marissa Town, RN, BSN, CDCES
