Medicare has two “coverage” codes for insulin pumps; “insulin pumps” (the original code) and “disposable insulin pumps”, the code created for the Omnipod. Insulet (Omnipod) initially tried for coverage under Part B but there were objections. This may be Omnipod was not offered under a “capped rental” scheme (“lease-to-own” or “hire purchase”).
It’s a cost issue for me too as I pay an extra $2,000 a year to use Omnipod just because it gets the disposable code.
Most of the Medicare code discussion has, unfortunately, been lost as it was on TuD. To complicate things the rules are set not by Medicare itself but by a part of the Federal Government, the Center for Medical Services (the “CMS”) which is effectively subcontracted by Medicare to administer the benefits. This is the same as Blue Cross being subcontracted to administer state or employer health benefit plans. The CMS rules start here:
Etc, etc, etc. Read section IV then look up all the E codes in there. Note that there are specific rules for AIDSes and the twiist combined with the CGM is an AIDS. A doc can separately prescribe Omnipod Dash pods with a CGM and this is what I have; so I’m not covered under the AIDS rules. It’s not clear if the O5 is covered without a CGM but I suspect that is up to the supplier (see below) because there doesn’t seem to be an “AIDS” E code.
All of the CMS rules are implemented in a way that makes them descriptive of the device. They don’t name specific devices. @andrea8 got coverage under Medicare with the balance paid by medigap. The information is somewhat scattered through the posts but @Terry you are on that thread too:
In this scenario the twiist and CGM (LIbre3+) come from a DMEPOS supplier (Byram, Edgeware, Edwards etc) presumably as an AIDS supply. The supplier gets the diagnostic information and maybe the codes from the endo (an endo is pretty much a requirement), makes sure all the requirements are met, and bills Medicare via the CMS (the administrator).
The medigap coverage is not involved in this; Medigap is pure insurance and is secondary insurance. It picks up the bill after Medicare has finished paying. The coverage is determined solely by the plan letter; the plan provider only affects the premium. Medigap is also for life; it can’t be cancelled by the insurer so long as the premiums are paid etc.
What does matter, however, is how it gets billed to Medicare and this is, at best, arbitrary. Here’s a PDF on the CMS web site:
Horrible, unnecessary, stupid. I believe the 2028 changes to this are still on-the-books and that will change everything to a pure rental model; not lease-to-own.