Medicare Hoops and Insulin Pumps

November 11, 2015

How much time do you and your patients spend unraveling Medicare red tape? Can you relate to our blogger’s frustration?

Not too long ago, I wrote a post about continuous glucose sensors and how they are not covered by Medicare. Several of my just-about 60-year-old patients have another dilemma. They have a continuous insulin infusion device that is not covered by Medicare.

Medicare does cover insulin pumps. There are a few extra hoops that have to be jumped through that most other insurance companies don’t insist upon. Medicare requires a C-peptide be measured and it has to be low. I can (to a certain extent) understand this. I don’t understand why they need it more than once. Once you stop making insulin, it’s unlikely that you will suddenly start making more. They also require documentation that the patient is seen every three months. It doesn’t matter if the patient is stable and the settings have not been changed in years. It doesn’t matter if the patient uploads his pump weekly and the physician reviews it every week. The patient needs an office visit every three months and a form needs to be sent documenting such. I have one patient who is very unhappy with this rule and thinks we doctors are in cahoots with Medicare and just want to make an extra buck. His visits are so joyful. Not.

There is one insulin delivery system, however, that Medicare does not cover. Because it is different than the traditional pumps (there is no tubing), it is not considered a pump and is therefore not covered. They consider the pods (which house and deliver the insulin) to be disposable, yet they cover the reservoirs and the tubing for traditional pumps, which are likewise disposable. Medicare does cover the meter/controller for the pods because that is durable medical equipment, but what good is that part without the pods?!

So I have at least 5 patients now who are around 60, approaching Medicare, doing very well on their insulin delivery system, and worrying about the future. Two of these patients have such disabilities that they cannot use a traditional pump, and certainly cannot go back to multiple daily injections. I have many more patients in their 50s who someday will be in this same boat. I have encouraged them to contact their Congressmen as it will take legislature to make what is basically a change in Medicare law. I know there are tens of thousands of people using these devices. Granted, most of them are young, but since eventually this will affect them, too, I am hoping that a change is made sometime soon.