GreatWest Healthcare « Salty and Sweet

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April 29, 2008 at 7:33 am | In Challenges, Cystic Fibrosis, Cystic Fibrosis Related Diabetes, Nutrition, continuous glucose monitor, diabetes, insulin pump | Leave a Comment
Tags: GreatWest Healthcare, health insurance, insulin, insulin shots, insurance, insurance appeal

I think it is time for an update on the case of the un-insurance-covered insulin pump and continuous glucose monitor system.

My doctor said we are finally ready to pursue my final appeal of insurance coverage for an insulin pump and continuous glucose monitor. It took a while to find and compile research studies since simply there are so few (we even had to wait for one to complete!). CF related diabetes is very rare, considering the size of the general population and it is also a fairly newly discovered complication of CF only since us cystics are living so much longer now days. I have figured there are only approximately 4,000 people in the US with CF related Diabetes. Finding info on it, none the less, hard data and research studies is very complicated.

Regardless of this, my insurance companay doesn’t care that I need to take up to 8-9 insulin shots a day, if I were to follow my prescribed nutritional needs. That is on a rough day. At a minimum I take 5 shots a day. Most diabetics with Type 1 diabetes take about 3-4 shots a day, minimum. My nutritional needs are much different than someone with Type 1, which makes things even harder to balance. My insurance company is not allowing coverage for an insulin pump because I do not have Type 1 diabetes…. now does this sound fair to you?!

I sent in my paperwork the other day, and my doc is sending in her stuff soon. Please wish good thoughts and send positive vibes for me and my future pump. Hopefully this time the reviewers will actually listen to my doctor and to common sense!

Un-flippin-believable!

March 6, 2008 at 4:32 pm | In Challenges, insulin pump, insurance | Leave a Comment
Tags: appeal, decision, denial, GreatWest Healthcare, insurance coverage

Apparently I am not the only one having problems with GreatWest Health Insurance. I just found a mother who is having a VERY similar problem with GW, getting coverage for an insulin pump for her son. Here is her story, copied off of a diabetes forum:

“Great West Nightmare”

Hello all ….

Am brand new to the site..and am looking for some guidance. My son was diagnosed back in October 06, at the time we were on KY State health insurance, and a few months down the road were looking forward to getting on the pump. Just as we were getting everything in order my hubby was hired to a new company and a new insurance company…Great West. All the information from the State Insurance was forwarded onto Edge Park and Great West..(mind you this took place in July/Aug 07 and the State Insurance was prepared to get the pump.) At that point everything kinda went haywire…We were denied the pump from Great West because his c-peptide level was normal.

At this point after many calls to our primary care provider, who I have great faith in..(if not his office staff -who refuses to return my calls), am at a loss as to what to do now..Do we need to retest his c-peptides..??..

I know the insurance company is playing the “game” but I am just sick of it. The medtronic folks I had originally talked to have all but vanished after assuring me they would help out in any/all appeals…

Do I need to camp out at my doctors office until he gets on the phone and makes the next level of appeals? My son in the meantime is going thru puberty…so his monitor levels look like a roller coaster ride…from 40’s to 300’s etc..etc.. depending on the day/time and activity level.
He is athletic and wants to play baseball and football again..(he played last year just after he was diagnosed.) but all these spikes are wearing on me. Is it me or is this is just plain nuts.

I kid you not! I have GreatWest Healthcare, I am trying to get a Minimed pump through Edgepark Medical Supply, I have a normal c-peptide test, and I TOO am being DENIED coverage from GreatWest! Our stories are too coincidental. I have been in touch with this wonderful mother, and we are going to share our tips and tricks so maybe both myself and her son can get GreatWest to cover our much needed insulin pumps.

Denied again – Update – the letter

February 15, 2008 at 11:42 am | In Challenges, Cystic Fibrosis, Cystic Fibrosis Related Diabetes, diabetes, insulin pump, insurance | 4 Comments
Tags: appeal, CGMS, decision, denial letter, GreatWest Healthcare, insurance coverage

I received the latest letter of denial from my insurance company.

Here’s what the letter says:
“This appeal was reviewed by an independent external consultant, Board Certified in Internal Medicine with a Sub Specialty Certificate in Endocrinology Diabetes & Metabolism….
… Although the patient has met the criteria of being on on intensified insulin therapy program, and has a hemoglobin A1C of greater than 7%, there is no documentation to support low endogenous levels in the member. Her C-peptide level is within normal limits, which is not unexpected, since cystic fibrosis is associated with impaired glucose tolerance rather than primarily decreased insulin production.”

Now, I am quite confused. I thought that CFRD was caused because of decreased insulin production because the pancreas is damaged and not able to produce enough insulin to keep blood glucose at safe levels? Could their “expert” be wrong?!

(-sarcastic comment warning-) I am wondering if the independent reviewer believes that I am overweight (5′5″ 107lbs) and should control his assumption of “Type 2″ diabetes by dieting. OH PLEASE!!

Note: I do NOT have Type 1 OR Type 2 diabetes. I have CF Related Diabetes. It is a whole different bear all it’s own.

Here is the denial for the continuous glucose monitor:

“The continuous glucose monitor was denied again because it “is still considered experimental and investigational, with the therapeutic benefit yet to be proven in large-scale long-term studies. … continuous glucose monitoring system is considered experimental / investigational / unproven and is not in accordance with generally accepted standards of medical practice at he the present time, it would not be considered medically necessary.”

Does any one have any comments or suggestions about how to refute this claim??

I have found out that my insurance, GreatWest Healthcare, is notorious for denying coverage for insulin pumps. Unfortunately I can not switch my insurance policy, as it is the only one offered by my employer.