So, after 3.5 months I managed to achieve full in-network coverage for the Tandem+G6 pump system. The fight was initiated because of the sole source agreement between UHC and Medtronic taking away my and my doctor’s choice of medical equipment to meet my care needs. My point is writing this post is to provide the outline of what I pitched to UHC as part of the appeal process.
My appeals package was structured and included the following:
- These type barriers are extremely frustrating and emotionally draining. However, throughout the process I kept on my Engineering hat and ensured all of my correspondence of data driven and not frustration driven (i.e. “You guys are mean and that pump sucks…you jerks” does not work).
- Arguing that a Tandem Pump is better than a Medtronic pump will fail. You have to separate the written argument into system level components, and the pump is the most interchangeable part of the system. Their form factors are different, but at their hearts they are just an insulin reservoir holder and pump drive mechanism. In my data package I actually stated, “Both the Tandem and Medtronic insulin pumps are solid mechanical devices….”
- The Sensor system integration is the key data driven differentiator. I did a statistical comparison of sensor accuracy data of the G6 verses the Guardian and showed while both are FDA approved, the G6 was more accurate reducing hypoglycemic event risk (i.e. long-term diabetes complication cost and/or death).
- Next, I compared the cost of having to calibrate the Guardian with BG testing strips/meter to not having to calibrate the G6. There is a personal cost and insurance benefit cost that is not statistically insignificant over the 4-year life of the pump.
- I did a similar annualized cost comparison of the sensor life 10-days verses 7-days, showing another cost benefit for the G6.
- Finally, I made the point that the Tandem pump is the only G6 integrated pump system providing both the life cost savings and life safety benefits.
- I included printed copies of multiple message boards detailing issues with the Guardian system and poor Medtronic patient support. I was selective as you would expect to make my point (there are good stories out there too).
- I included all data sets in print form for their review. The point being to be transparent and make ensure the argument is about data.
- I also included Letter of Medical Necessity (LMN) from my Endo that she and I work quite a bit on together to drive home the point that ADA and AMA guidelines clearly state medical decisions are to be made by the doctor and patient. My Endo is fantastic advocate and doc.
- Lastly, I got my HR rep on-board as my advocate. This took me meeting with her three times with my dataset (including the UHC sole source agreement) to educate her on the issues and trades. She was great. She knew little about diabetes care and was open and willing to learn. She also took the time to understand and recognize that we typically know more about pump tech and care than any insurance carrier or HR department. We are continuing to work together to try to get a “carve out” included in my company’s 2020 carrier renewal.
You must get a denial from the insurance carrier first to proceed to the appeals process. The appeals process will require that you mail your appeal and supporting documentation….yup…I said mail….that stamp and envelop thing we used to do. The appeal is sent by Pony Express and Carrier Pigeon to the UHC offices in Utah.
Finally, I accepted the initial denial on in-network coverage and went ahead and bought the Tandem pump/sensor through my out-of-network benefits. The appeal process was done post-receipt of the pump. I only mention this because I do not know if this has any bearing on the final outcome…but is a potential variable.
Last Comment….Be persistent. Don’t accept “No.” Your willingness to keep pushing the system to be patient focused before profit focused helps us all in the long run. Persistence backed with data is hard for a business to rule against because it places them in a precarious legal position if something were to happen. The true cost differences in these pumps is small in relation to a business taking on that risk. You just have to make them realize this fact.
Best of luck and thank you for your efforts to fight for us…