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July 29, 2001

Insurance/Costs

Question from New Orleans, Louisiana, USA:

I am 18 years old, was diagnosed with type�1 diabetes a little over two years ago, and since then, I have tried many different types of insulins, but, no matter what is tried, I seem to either wake up really high or have severe lows during the day. I am a sophomore in college and have a different schedule day to day, so it is impossible to try to fit diabetes around my schedule. My doctor and I have been bugging my insurance company about purchasing an insulin pump, but because my hemoglobin A1c isn't high enough (in their mind it has to be at least 9.5%) they won't justify a pump. Because of the disastrous lows, my A1c is only 7.9%.

Answer:

An insulin pump may be helpful even if your A1c is not extraordinarily elevated. An A1c of 7.9% is not terrible, but certainly is not normal. DCCT. goals suggest that you should aim for values less than 7% without excessive or severe episodes of hypoglycemia. You can continue to argue with your insurance company even if they reject your request initially. There is certainly sufficient medical literature to back you up.

SB
Additional comments from Dr. Phillip S Ledereich:
I would consider calling the pump company as well to contact the insurance company with information about the pump showing them that better control would help them save money in the long run with decreased complications.

Consider also calling your state’s insurance board because of the denial of treatment, as well as your elected officials. Consider contacting the ADA as they have lawyers who work with people with diabetes with issues such as this all the time.

Do not take no for an answer. Good luck.

PSL

[Editor’s comment: Be sure that your doctor has written, and the insurance company has seen, a “letter of medical necessity.” I sometimes think that insurance companies reject things without looking at them, but if you and your physician continue to try, eventually your doctor should be able to persuade the correct people — the medical director of the company, the appeals committee, or whatever mechanism the insurance company has in place to deal with dissatisfied patients. And if that fails (assuming you have the letter from your doctor!) be willing to ask for outside help, as advised by Dr. Ledereich.

WWQ]