Monday, December 9, 2013

Choosing An Insulin Pump: The Empire Strikes Back.

[An update/resolution to this post can be found here.]

"I have heard there are troubles of more than one kind
Some come from ahead, some come from behind
But I've bought a big bat, and I'm all ready, you see
Now my troubles are going to have troubles with me"

- Dr. Suess

It hadn't really occurred to me that obtaining a new insulin pump to replace my soon-to-be-out-of-warranty one would be a challenge. Based on my past experience, I figured that filling out all of the paperwork would be the most difficult part of the process (and God laughed): the warranty on my Animas Ping expires at the end of this month, so of course I need a new one. The pump's housing is quite scratched up, and the buttons are not as responsive as they once were. The pump's technology is now at the very least five years old (FDA approved the Ping system for sale in July of 2008), and doesn't have many of the features that newer pumps offer patients.

Except that Cigna and Care Centrix (my insurance and DME providers) don't seem to agree.

For a company that says they are "dedicated to helping people improve their health, well-being and sense of security", I'm sure not seeing it. Using a medical device that's endured four years of use and (inadvertent) abuse is going to help my "sense of security"? Do you know how many times this pump has been dropped, knocked around, or been exposed to snow and below-freezing temperatures? It's the nature of wearing a medical device 24/7 for four years. It's normal wear-and-tear.

This process started with me filling out patient info forms with both Tandem and Asante (figuring that since Animas was already approved for me, I didn't need to pursue that route), and my doctor faxing over the needed signatures and documents. It's been a few weeks since we did that, and an insurance verification rep from Tandem and I have been emailing back and forth periodically throughout the process (asking when my current pump was purchased, if it was still in warranty, etc.). When I answered that my pump was purchased in December of 2009, the rep responded positively. "Great news", she said.

And I thought it was, too.

Except that her follow-up email said this:
"Just got off the phone with CareCentrix. Per CCX the expiration date does not warrant a new pump. They state the current pump most be malfunctioning or not meeting your medical needs."
I  responded by telling her about the pump being scratched up, and the buttons not working consistently.
"The only way we can get this approved is if we could show your A1C’s being effected by the current pumps malfunctions. Looks like your last A1C’s were in the 6’s which would be considered manageable. We may have to wait until the warranty is up on the pump and the functionality is no longer meeting your medical needs."
Expressing my disappointment, I told the Tandem rep that I'd be contacting Cigna. She added that she was very surprised to find out that Cigna does not have an automatic approval policy for a new pump when the old one is out of warranty - to her knowledge, they are the only carrier with that policy.

I also want to point out that the Cigna employee used the phrase "entitled to" when referencing my ability to obtain a medical device that makes a huge difference in how I am able to manage my health.

I took to Twitter.

And then, a ray of sunshine:

You bet I'll email you. R2? Fire up the converters!

Because the thing is - it's great that I have an insulin pump already, and I'm thankful for it. It is one tool among many that has helped me attain what is apparently the only criteria that Cigna cares about - a "good" A1C result.

What Cigna fails to factor into their judgement here is that A1C isn't actually a great summarization of my diabetes management - it simply provides an average. It doesn't factor in standard deviation of glucose values, it doesn't predict the chances of me developing complications, and it certainly doesn't relieve any of the cognitive burden of managing this disease all day, every day. My A1C doesn't tell them how I attained that result.

And what Cigna/CareCentrix also fails to recognize is that part of the reason I'm okay NOW is that I have been able to use the best of what's available NOW. If you want me to continue to be healthy in the future, I need to be able to use the best of what's available in that future. "You're doing okay with what you're using" is the exact argument FOR a new device being approved. Let's make sure I keep doing okay.

What this boils down to is really simple - Cigna/CareCentrix can either pay for a new insulin pump now (because that is the treatment option that is most effective for me, given what's currently available), or they can wait until I've experienced any number of adverse health outcomes that result when this old insulin pump malfunctions and pay for any resulting hospital charges. Show me where that fits into their mission statement of "helping people improve their health and well-being".

Do I sound dramatic? Good. This is my life and my health we're talking about, and I take that health very seriously. Give me the tools I need to help me be healthy, and it will save you money in the long run, Cigna. If the technology is there, let me use it.

Let all of us use it. This isn't just about one person with some degree of social media influence fighting for what she needs - this is about every person having access to what can help them achieve good health. This is about all of us, and moral issues aside,  it's to a payer's financial benefit that their customers have access to the baseline preventative care they need.

I will write whatever needs to be written; show whatever needs to be shown; speak with whomever needs to be spoken with; do whatever needs to be done. Their policy is wrong, and I'll be happy to tell them exactly why.

(Where things stand as of this posting: Cigna has spoken with CCX and the request is being looked at again. I'm working with my endo's office to get CCX whatever proof they need to get a new pump authorized and covered.)

"Sir, the possibility of successfully navigating an asteroid field is approximately 3,720 to 1." - C-3PO
"Never tell me the odds." - Han Solo


  1. When I was in Italy, I missed American insurance companies (something I never thought possible). Now that I'm back and dealing with the corporate backlash to the Affordable Care Act (in my case, I now pay 30% towards all of my durable medical equipment instead of formerly paying 0%) I miss government-run health care that acknowledged that certain things are completely out of the patient's hands and he or she shouldn't be penalized for it. Sigh.....

    Good luck getting a good result on this.

  2. I'm am so PO'd and frustrated for you! Your life and your health are worth the fight!

  3. I absolutely HATE policies like this, because if the pump fails after a warranty is up, the PWD will be in a jam to get a new one, and the one that they want. And I don't know about you, but my backup plan is not as effective as my insulin pump. It's there only to get me back to the pump.

    1. Isn't this why it's industry standard to have an automatic approval policy for a new pump when the old one is out of warranty!? Cigna what are you doing. GL!

  4. The system is broken and patients suffer. The people who decide these things (at least at first go-round) are not medical professionals. I had to fight through an appeals process with my insurance for a new CGM, while living without one since my previous one had stopped working, in the process, I had a dangerous low blood sugar that I didn't feel because I am hypoglycemic unaware and with the previous CGM I didn't have any "evidence" of it.

    I hope that this situation is resolved quickly and a new pump is covered without your health having to be endangered.

    I dread the day when my warranty runs out and I need to fight a similar battle (and I know I will).

    1. That's just it - they don't see any adverse health outcomes now, BECAUSE IT'S WORKING. What about when this pump breaks? It will still take weeks for a new pump to arrive at that point, and meanwhile I'm left hanging.

  5. It's really hard to feel that insurers don't make a practice of systematically delaying big-ticket claims, though this is probably not true. I had a refill (a fairly expensive one, alas) that I feel that I NEED in limbo for over a week while my insurer pondered a preapproval that they've said "yes" on at least twice before. I find it a somewhat bitter irony that my main work activity during this time was running our open enrollment system - in other words, helping staff sign up for health insurance.

  6. UGH. This angers me so much. What the hell do we pay our premiums and deductibles for? So we can get this stuff covered.

    I wonder if you will have more luck after the first of the year (assuming that is when your deductible refreshes). Perhaps they want to get more cash from you? Doesn't make sense, but it could be an evil game they are playing.

    GOOD LUCK and keep us posted. I have Cigna/CareCentrix too.

  7. Kim, I understand where your frustration is coming from. Over a year ago I made the switch from my Animas Ping to my t:slim. And I too had to battle for it. I was just shy of my own warranty end with Animas and I too was told by my insurance company that they would not approve me for a new pump unless and until my current one was malfunctioning. The reason I wanted to go to the t:slim is because of the full color screen.....because of my retinopathy and damage I've sustained from the laser treatments needed I found it impossible to see my Ping screen when in sunlight (outside, even just in my car on a sunny day) and I found this unacceptable and dangerous. Yes, I now love my t:slim for other reasons, but this was the first and foremost reason I pursued it. When I was denied I went to Tandem and asked what I could do. I was told that because I was pursuing this based upon my eyesight it might be deemed 'medical necessity' and I could try to get a note from my endo explaining this. So I went to my endo and he submitted a letter stating my medical history (including A1c levels pre and post pump, my retinopathy diagnosis and procedures related to it, current eyesight levels (I assume he spoke to my retinologist for this))....and suddenly I was approved. The moral is: you can and will do this. Fight for it until you get it. Insurance companies notoriously suck and make snap decisions based on almost no info whatsoever. If you keep talking to them and giving them more info they are more likely to slow down, listen, and rethink their decision. Best of luck to you!

  8. I really hope that this all works out for you. It's crazy that it's got to be a fight every time to have one's health seen as something more than a monetary amount by their insurance companies.

  9. I totally hear you. Many years ago, when I first wanted an insulin pump, my insurance company at the time (who I think may actually have been Cigna) said I was "too healthy" for the pump, meaning I was at a healthy weight and my A1Cs were in check. My doctor wrote them a note and they finally approved, but the whole process really soured me on the whole thing. Good luck!

  10. This kinds of processes are the norm, rather than the exception. Deny first and seek an appeal is the routine according to Wendell Potter who was a former executive at Cigna of all companies who testified that was the operating procedure for most for-profit healthcare plans. Some are much better than others, but I suspect its more a matter of finding the procedure, and this is an area where Tandem and Asante don't quite have the process down as well as the longer-established rivals do, although that's no excuse for them (learn fast, startup pump manufacturers or your venture capital investors will see red!). I went through some of this when Animas began as one of the new competitors to Minimed (which had just been acquired by Medtronic at the time). Also, make the startup do its job -- they'll lose a sale if they don't step up.

  11. Thanks for sharing. I've been trying to find a way to explain the irony in these situations, and you've done it perfectly here. I believe some (not all) companies like to deny first on items like this, hoping you won't fight as hard as you're doing. I feel for people who don't know their rights and will give up after getting a denial like yours. Keep fighting... you have everything to gain, and everything to lose.

  12. The same companies denied my request for a pump earlier this year because I did not have a history of DKA. Interestingly, according to them I also did not have a history of ANY DIABETES. I short of wrote it off as my ancient Dr (I was a new patient in a new town) not being a strong advocate for me because he seemed afraid of technologies when I asked about them).
    CIGNA did approve a CGM for me in October, but with only 2 boxes of sensors. Until next year when I will get to pay the deductible again.
    It does appear that their stable bottom line is their #1 priority, not maintaining the health of their customers.

  13. I think your pump might get run over by my car soon. That would be terrible. I fight with insurance companies all day over issues like this. It's endlessly frustrating, and I don't see it getting any easier. I now realize how lucky I was to have my pump approval breeze through a few weeks ago. Little did I know!

  14. Holy moley....what a headache - I think I will be trying out the omnipod next. (hopefully its better than my last go around...

    xoxo from Trinidad

  15. This is the stuff that makes my skin crawl! How dare they deny you access to a pump when yours is clearly out of warranty!? And GREAT point on the A1C. I am SO tired of that being used against me. What you fail to realize is that sometimes it's a result of floating in the high 200s and then sitting at 75 all night. How is that the golden measure of what I need to improve and maintain my health. Good luck!

  16. I don't know if it is a Cigna problem or a CareCentrix problem but UGHHH!!! You know that the only reason that insurance companies contract with third party suppliers (CareCentrix, Edgepark, etc) is to save them money. That is the exclusive job of the supplier. That is why I went around and around and around with one of the companies for MONTHS about my Dexcom system and why it took an external audit and MONTHS of overpayment for my pump supplies to accurately be accounted for with another.

  17. A very disheartening and obnoxious game made possible by for-profit insurance (and perhaps also the inexperience of Tandem?). It is as if the first person who reviewed your initial claim is new to the job and doesn't understand T1 and that it isn't ever going away and you are never going to let this first level denial stop you. The employees are trained to reflexively deny claims because it is in their best interest (money) to do so. They are hoping you give up, switch jobs/health plan, or die. There is a special ring in Hell reserved for these folks. I love how the customer service rep tried to stop your Twitter bash, lol. Don't fret the their stated reasons for denial which are just their way of justifying denial of coverage. It is a game where your doc and Tandem have to somehow word your request more strongly. You will get your new pump because Cigna will realize you won't give up and will appeal and their doc would have to sign off on it being okay not to approve your new pump.

  18. Have you seen the trial JDRF is doing with the artificial pancreas system and inhaled insulin? Looks very exciting. There is a video on youtube, results I think are going to be released shortly. JDRF, sansum, and UCSB working on it. It seems to address the actual root of the problem, bing post prandial excursions, and helps diabetics get closer to normal function instead of just harping on A1C.
    Good luck to you and I wish you well in your efforts fr better treatment.

  19. A belated perspective: I've had Cigna (and Aetna, Anthem, Humana, UnitedHealthcare and a few others) and none of them are interested in long-term health consequences for their policy-holders. For T1Ds, this shows up in myriad ways, including the "if it ain't broke, don't replace it" policies that require your health to suffer first. Further evidence is the Quantity Limits they all impose on glucose test strips and the bribes ["rebates"] they take to place brands on their Formulary Tiers.

    Insurers would prefer us to die. If we don't die, then they would prefer that we buy insurance from one of their competitors.

    The best ways to combat this inherent profit motive are persistence, advocacy and public shaming -- so keep up the good work!

  20. I know this is an old posting, but I am dealing with this very problem right now with Cigna/CareCentrix--the extra twist being that I have a Snap pump from the suddenly-defunct Asante! Cigna/CCX has denied me getting a new pump (I was trying to get a Tandem t:slim) because my Snap is still operational--even though a) Asante is out of business so there's zero tech support if something goes wrong, and b) there is a very finite number of Snap supplies left. CCX's response? "Well, you just might have to go back to MDI's"--really?!? I have been on insulin pump therapy for over 13 years--I wouldn't even know HOW to go back to MDI's!! Forgive me if this is posted elsewhere, but what was the outcome? Did your issue get resolved? My husband's benefits coordinator at work is trying to hash things out with Cigna; part of the problem is the company suddenly switched from UHC to Cigna less than a month ago, with a supposed promise of "no changes in plan coverage," but it seems Cigna is NOT living up to the coverage we had with UHC. I've felt sick about this all day--my life depends on this stuff!!

    ~ Jennifer

    1. Jennifer! I am so sorry this is happening to you. :( Here was my resolution: Having your doctor write them with the potential dangers of not having a warrantied pump may help - get them on your side too. Let me know if I can help. Good luck!!!

    2. Thank you, Kim! My husband did point out to me that there was a link to an update, which my eyes--connected to my upset and panicked brain--did not see initially, sorry! I am so frustrated about what you went through, but it's almost a relief to read your story and know that I am not the one going nuts over here (my husband's benefits coordinator probably cringes every time she sees my emails pop up on her screen, LOL). All of this happening at once (change of insurance provider, Asante going out of business, my suppliers for pump and Dexcom suppliers not being contracted with Cigna, administrative errors in the transition, etc.) is maddening. Amazingly, my #'s have stayed in the 90's all day--although I am sure my blood pressure is through the roof! :\ Thank you for the encouragement!!

  21. Hello,
    Cigna had a psychologist who can't spell not an endocrinologist issue a deny order from my child's pump. They gave a similar reason and his current pump is out of warranty. My experience is that if you hit a wall you go under it, if you can't go under it you go over it. If you can't go over it you go around it. If that does not work you go right through the damn wall. My child's life is at stake if they think I am just going to go away they are sorely mistaken. The right person can have more power then all of Cigna. They will learn this the hard way. Results matter not the fluff they are feeding us:
    “Never, Never give up on something that you can't go a day without thinking about.”
    ― Winston Churchill

    “If you're going through hell, keep going.”
    ― Winston Churchill


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