It only took us 8 months, 4 appeals, and probably a hundred pages of writings
As you know, UHC denied, in November, our request for an Omnipod for my sports loving son who is a big swimmer. They denied every one of our subsequent appeals. Today I opened a letter from the third party appeals organization: their endocrinologist overturned the determination by UHC.
I am happy to share with anyone undergoing the same problem our trials, tribulations, and lessons.
A million thanks to @Eric. I don’t think we would have been successful without his help. He spent hours reviewing content and helping make it better.
This is tremendous!! So pleased it came through, though still terribly frustrated that it required so much effort. @Kaelan, congrats! You’re going to love it!
CONGRATULATIONS! That is fantastic news for you guys!
Thank you! I just spent a sleepless night on persistent lows, but this is really cheering me up!
I can’t even begin to express how happy this makes me. I remember how overjoyed I was when I got the letter overturning the United Healthcare denials.
I went through this last year, and the experience I had with United Healthcare changed me a lot. Before going through this, I never had any interaction with any other diabetics. I just did my own thing, and was totally on a diabetic island. No discussion, no interaction. Just took care of my own D business.
When they denied me, it did two things. For United Healthcare, it created an enemy for life. And for any diabetic that needed anything, it created a friend for life. That is what UHC did.
For anyone that needs help with UHC, I am ready.
If you don’t mind me asking, what reasons did the third party give for overturning UHC’s decision? The reason I ask is that my doctor supports me trying a pump. She prescribed me the Tandem X2 (I already have a Dexcom 5, which I got after a third party review). She really hates the Medtronic pumps. UHC is telling me that they will only approve the Medtronic pumps as they are the only pump “covered device” in my plan.
David, I remember very well the letters I wrote, but I will need to re-read the outside appeal decision to be able to give you a full read. It will take me a day or two.
If I phase out for some reason, do PM me to ping me. I just received a delivery of 175 cardboard boxes that I must fill and move to storage, so I may well not track my todos as well as I should!
Just a very general description - it needs to be shown that is is the only pump you can use. The difference is that the omnipod is the only tubeless pump, so why is a tubed pump unusable?
It can’t be anything such as you like it better, or you don’t want to use a pump with tubes. It has to be that you are unable to use tubes, for whatever life-circumstances you have.
Have you already gotten denied? Where are you in the process?
You will not get it unless you can get it through a pharmacy benefit that is covered differently, or you do an external appeal after UHC denies you.
If I recall correctly, @TravelingOn and @EricH got it through pharmacy coverage, so they can tell you a bit about that process.
Yes! We have a UHC PPO plan and expected to get rejected. Strangely, the OmniPod pods are covered through the pharmacy benefit. We receive them through a third-party-provider called Advanced Diabetes Supply here in California. We paid out of pocket for the PDM.
We had a bit of a screw up when we ordered the PDM and were charged 3x the Insulet quoted price by Advanced Diabetes Supply for the PDM (@EricH and I were somehow not both on the emails/phone calls with Insulet).
Anyhow, the pods are covered (with a hefty copay) monthly by our pharmacy benefit (although ADS screwed that up in December too, but we were leaving the country and so I haven’t taken it up with them since I didn’t receive a returned phone call before we left.)
@Eric and @Michel were both immensely helpful in explaining to us what OmniPod use was like and how they went about the process of applying for an outside appeal. I was ready for quite the drawn out experience.
I will note: make sure your doctor is on board (sounds like they are!) and that you’ve got time to begin and proceed with the process.
And Good Luck!
Basically, the third party reviewer found that aside from my type 2 diagnosis, I met all of the other criteria that UHC established for approving a cgm. I had a history of compliance in all therapies and educational opportunities recommended by my doctor. I was injecting three or more times per day. I was checking my blood glucose level three to four times per day. Perhaps most importantly, I had recent history of multiple hypo events along with some difficulties with postprandial highs. The individual opined that my type 2 diagnosis should not (in itself) prevent me from having access to diabetes interventions/treatments.
I hope this information helps.