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May 12, 2002

Insurance/Costs

Question from Great Lakes, Illinois, USA:

My four and a half year old son has had diabetes for almost two years, and our insurance company is trying to change how often we see the endocrinologist from four visits per year to one. They said we will need "proof" we need the specialist more often because we can have the A1c done at the local pediatrician's office. Are four visits per year standard? Is this change prudent in maintaining control of my son's blood glucose? I am very concerned about this. He is still in the honeymoon, but we know this will not last forever. It often doesn't seem like she "does" anything more than the pediatrician does but our specialist is always available to answer our questions and

Answer:

Fight with the insurance company since they have no legitimate right to dictate how often a specialist is consulted. This is a decision that you make in consultation with your primary care provider. There are many recommendations from the International Society for Pediatric And Adolescent Diabetes as well as articles in the literature, including one that I wrote in Diabetes Spectrum several years ago. There are several articles that suggest but don’t prove that specialty care is better for folks with diabetes, more eye checks, more BP checks, more checks of hemoglobin A1c levels, lipids, thyroid functions, etc.

I would suggest that a minimum of visits to a pediatric diabetes team should occur every three months. Our group usually recommends visits every four to eight weeks. The DCCT protocol included visits every month.

So I would argue with your insurance company that they have no right to dictate specialty consultation visits at all. Your own specialist should also be able to write a letter specifying details of why more visits would be in your child’s best interest and include specifics of the treatment plan to help you convince your insurance carrier.

SB