I have been Type 2 for 15 years and using MDI. I have attempted to get a pump via Medicare Advantage. Tandem requires that I have a c-peptide of 5.5 or lower and a fasting < 250. My c-peptide is 6.2 and until now I never went over 210 after meals. Do you have any ideas on how to get a pump?
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I’m surprised Tandem requires c-peptide to get. Unless they assume having pump insulin plus pancreas insulin would not work well, not tested, or knowing it is small customer need.
Or may be Tandem relaying requirements for c-peptide from insurance coverage, which is common.
Medicare definitely requires testing. Employer plans may vary.
I got first pump in late 80s, was dx at age 5. And I still had to have c-peptide tests when switching insurance. And this year will switch to MC, and may need to have it checked again.
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I don’t think it’s Tandem but Medicare. Medicare has harsh rules on pumps, especially for type 2.
I am away from home or I would quote the exact requirements for pump coverage.
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I was just relaying what original post implied that Tandem was requiring it.
Agree that the payer/insurance usually makes the requirements for approving/denials.
Most use the C-peptide test.
My first pump was in mid 80s, and had to get current c-peptide each time my insurance changed, and likely need to prove to Medicare one more time.
I make no insulin!!!
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I don’t believe Medicare will cover an insulin pump for a type 2. Rules change, I suggest you call your insurance company and ask them what the criteria for coverage is.
Per Medicare
“When considering both cost-effectiveness and risk-benefit, there are no compelling reasons to widely use insulin pumps in patients with type 2 diabetes at this time.” Advantage plans are not likely to cover something regular Medicare doesn’t.
NCA - Insulin Infusion Pump (CAG-00041N) - Decision Memo.
Here is a lengthy article about pumps.
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I am on an Advantage plan as a retirement benefit, and my pump and supplies as covered even though I am type 2.
I don’t ask why because I don’t think I qualify.
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That’s wonderful @CarlosLuis. It does say no compelling reasons to widely use for type 2’s, that seems like there might be some wiggle room? But don’t rock the boat!!!
But rules change as Medicare is now covering some CGM’s for some type 2’s now. And then we know all the different insurance companies have their own rules. And sometimes some things just slip through the cracks, and sometimes it’s how the doctor writes the request and possible appeals.
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Since this came up again, it’s not the “type” it’s the insulin production. So docs have a criterion where they prescribe insulin for diabetics based primarily on how much insulin they produce. The “fasting” test shows the lowest production because there is nothing to produce insulin for.
The CMS uses a criterion based on that.
Eventually someone diagnosed as “T2” might lose enough beta cell insulin production to cause everything to start to go into catastrophic failure, exactly as happens with T1 where there is no measurable insulin production. That’s what the CMS is trying to determine.
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It has done for me coming on 6 years come December.
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Here are the current rules for physicians. In fact these have not been changed since 2024 but it’s always worth checking because they do change:
The page is general for all infusion pumps but the insulin case (CSII) is in (B)(1)(e). I’m going to quote the section in full here because it’s pretty clear and is a regular issue, particularly for people identified as T2. I’ve added the italics, the bold is from the original page above:
e. Continuous Subcutaneous Insulin Infusion (CSII) Pumps (Effective for Services Performed On or after December 17, 2004)
Continuous subcutaneous insulin infusion (CSII) and related drugs/supplies are covered as medically reasonable and necessary in the home setting for the treatment of diabetic patients who: (1) either meet the updated fasting C-Peptide testing requirement, or, are beta cell autoantibody positive; and, (2) satisfy the remaining criteria for insulin pump therapy as described below. Patients must meet either Criterion A or B as follows:
Criterion A: The patient has completed a comprehensive diabetes education program, and has been on a program of multiple daily injections of insulin (i.e., at least 3 injections per day), with frequent self-adjustments of insulin doses for at least 6 months prior to initiation of the insulin pump, and has documented frequency of glucose self-testing an average of at least 4 times per day during the 2 months prior to initiation of the insulin pump, and meets one or more of the following criteria while on the multiple daily injection regimen:
- Glycosylated hemoglobin level (HbAlc) > 7.0%;
- History of recurring hypoglycemia;
- Wide fluctuations in blood glucose before mealtime;
- Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl; or,
- History of severe glycemic excursions.
Criterion B: The patient with diabetes has been on a pump prior to enrollment in Medicare and has documented frequency of glucose self-testing an average of at least 4 times per day during the month prior to Medicare enrollment.
General CSII Criteria
In addition to meeting Criterion A or B above, the following general requirements must be met:
The patient with diabetes must be insulinopenic per the updated fasting C-peptide testing requirement, or, as an alternative, must be beta cell autoantibody positive.
Updated fasting C-peptide testing requirement:
- Insulinopenia is defined as a fasting C-peptide level that is less than or equal to 110% of the lower limit of normal of the laboratory’s measurement method.
- For patients with renal insufficiency and creatinine clearance (actual or calculated from age, gender, weight, and serum creatinine) ≤ 50 ml/minute, insulinopenia is defined as a fasting C-peptide level that is less than or equal to 200% of the lower limit of normal of the laboratory’s measurement method.
- Fasting C-peptide levels will only be considered valid with a concurrently obtained fasting glucose ≤ 225 mg/dL.
- Levels only need to be documented once in the medical records.
Continued coverage of the insulin pump would require that the patient be seen and evaluated by the treating physician at least every 3 months.
The pump must be ordered by and follow-up care of the patient must be managed by a physician who manages multiple patients with CSII and who works closely with a team including nurses, diabetes educators, and dietitians who are knowledgeable in the use of CSII.
Some explanation:
- The “autoantibody” test can be extremely important for newly diagnosed diabetics because it shows the presence of the autoimmune disorder and therefore identifies the LADA cause of a T2 diagnosis. Attempts to measure antibodies later might turn up zero as a result of the antibodies having run their course and destroyed most or all of our beta cells.
- Step (2) must be met as well; it’s not enough to have an almost unmeasurable C-peptide or show the antibodies. Either it is necessary to already be using a pump (Criterion B) or it is a requirement to receive the education and then check one of the boxes at the end.
IMPORTANT
This is my actual C-peptide from 2023:
The test was performed by Mayo Clinic Laboratories. Notice that the “normal value” is 1.1-4.4ng/dL. Values like “5.5” don’t mean anything; it is necessary to give the units. 5.5ng/dL would be a high C-peptide suggesting a non-fasting test:
Notice that the paper above uses SI units (mol/L), whereas my test uses pre-SI units, which are fairly arbitrary but my test used g/L, the conversion factor is 3020g/mol because the molecular weight of C-peptide is 3020g/mol (3021 Daltons). So to convert from pmol/L (in the paper) to ng/mL (my test) the convertion is:
ng/mL=(pmol/L × 3020)/(1000 × 1000)
If I got the arithmetic right (Google reports the same conversion) the numbers work out as follows. The first two lines are for “random non-fasting” tests from the paper (converted to ng/mL) and the next two are the normal range of my fasting C-peptide converted to pmol/L:
| Condition | pmol/L | ng/mL |
|---|---|---|
absolute insulin deficiency |
200 | 0.6 |
Type 1 diabetes/inability to withdraw insulin |
600 | 1.8 |
Fasting C-peptide normal low |
360 | 1.1 |
Fasting C-peptide normal low |
1500 | 4.4 |
Fasting C-peptide low threshold (Mayo) |
33 | 0.1 |
Notice that my lab test apparently had a low threshold of <0.1ng/mL, that’s just 33pmol/L and, indeed, I’ve been a fully developed T1 (no insulin production) for years.
Not all T1 or LADA diabetics lose all insulin production so the CMS requirement is really low and fasting is an absolute requirement. This is my reason for suggesting that when a T2 diagnosis is transitioned to an IDD diagnosis it is a very good idea to get the antibody test done.
Medicare required a C-peptide test for me as a T2, even though I had already been on a pump for years. Hint…make sure your bg is on the low side (under 120 or even better, 90) when you have the C-peptide taken. If your BG is high, your C-peptide will come out high, too. Happened to me, so my doctor didn’t submit the first test, and we retook it when my BG was low, and I was accepted by Medicare for the pump.
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HI Carlos!
That comment was back in Feb 2024. The rules saying who could get pumps was different and narrower back then but there was some wiggle room. I believe it was mostly based on insulin production.
This was your reply then!
"I am on an Advantage plan as a retirement benefit, and my pump and supplies as covered even though I am type 2.
I don’t ask why because I don’t think I qualify.
"
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I got my pump Dec 2020.
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@marie’s point is apposite; retirement benefits extend the Medicare benefits. Part of this is covered starting at Page 19 of the 2027 “Medicare & You”. The situation has been raised before, either here or more likely on TUD, wrt TRICARE. There’s a big table on Page 21 about who pays but that does not prevent another “insurance” plan picking up the remainder; there’s nothing to stop an individual entity or a corporate entity from paying your or my health care costs directly.
Of course this is the ever increasingly complex US tax law, on which I am not permitted to utter a single word (perhaps partly because of what that word is).
However it seems clear that employer retirement benefits can cover Medicare costs after Medicare (so Medicare pays first) regardless of coverage by Medicare.
GenZ appropriate message: Read the small print on the potential employer health plan. When (more “iff”) you find one which gives you magnificent retiree benefits accept the job and then just dodge the PiPs for the next 40 years. Bear in mind that the corporation will go out of business on a regular basis; check the Chapter 11 clauses.
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