AskNadia: Why Medicare Covers Some Insulin Pumps
I was thinking about getting an insulin pump, but I am worried that Medicare will not cover it. Why does Medicare cover insulin pumps for some people and not for others?
Insulin pumps are covered under Medicare if you meet their insulin pump management criteria, insulin antibody test or C-Peptide test.
If you are thinking about getting an insulin pump, this is what you need to do.
The Insulin Pump Community
Anytime someone asks me about going on an insulin pump; I recommend they speak to someone who is wearing a pump or go to an insulin pump support group. The wisdom you gain from exploring these two venues is invaluable. After speaking to people who wear a pump, you will either decide it is the best thing for your blood sugars or too labor intensive and might try something else to achieve better blood sugar levels.
Don’t miss this important step.
Working with Your Healthcare Professional
Healthcare professionals are great at identifying who is best suited for an insulin pump. They know if you can benefit from using an insulin pump to achieve better blood sugars based on their experience with you and your medical chart. Start a discussion with your healthcare professional who knows you and has access to your medical history.
Let’s assume your healthcare professional thinks you will benefit from using an insulin pump because you meet the Medicare A or B criteria. Let’s also assume you have had an opportunity to speak to people that wear pumps and are very excited about getting started in qualifying for one; the formula below is the process Medicare uses to evaluate insulin pump coverage requests.
Medicare A Criteria is For New Insulin Pumpers
1- You must be on multiple injections and able to self-adjust your insulin for six months prior to going on an insulin pump. This means you take a minimum of three injections a day and can accommodate the blood sugar results by adjusting your insulin requirements.
2- You must test at least four times a day prior to going on an insulin pump, and this is documented by your healthcare professional. Two months of testing is required prior to going on an insulin pump.
3- One or all of this requirement below qualifies you under the Medicare A criteria in addition to requirements 1 and 2 listed above.
~ A1C of 7 or greater.
~ You experience the dawn phenomenon where you wake up with a fasting blooding sugar of 200 mg/dL
~ You experience many low blood sugars or, a history of severe low blood sugars
~ High and low blood sugar before mealtime
Once your qualifications are confirmed, Medicare will cover the training and insulin for your new device.
Medicare B Criteria is for People Already on an Insulin Pump
This requirement is for people who have been using an insulin pump prior to qualifying for Medicare insurance coverage. Criteria B requires that you work with a qualified medical team. It includes a physician, nurse and dietitians that all have experience with insulin pump therapy in a clinical setting; meaning they all have experience in working with patients in their office, which use insulin pumps.
Last important criteria, it does not matter if you qualify under criteria A or B, you must see your medical team every three months, when you choose insulin pump therapy coverage from Medicare.
Medicare NCD Manual 280.14, Section A.5
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Nadia’s feedback on your question is in no way intended to initiate or replace your healthcare professionals therapy or advice. Please check in with your medical team to discuss your diabetes management concerns.
Nadia was not only born into a family with diabetes but also married into one. She was propelled at a young age into “caretaker mode,” and with her knowledge of the scarcity of resources, support, and understanding for people with diabetes, co-founded Diabetes Interview now Diabetes Health magazine.
Nadia holds 11 nominations for her work as a diabetes advocate.
Her passion for working in the diabetes community stemmed from her personal loss. She has used her experience as a caretaker to forge a career in helping others.
For 25 years, Diabetes Health contributes free copies of the magazine to healthcare professionals and pharmacies that use the publication as an educational resource for patients living with diabetes.
One thought on “AskNadia: Why Medicare Covers Some Insulin Pumps”
I cant get any help i liv in texas i dont have insurance i have neuropathy in my stomach my feet an other problems im disabled an im only 34 yrs old last day i went too work i shot myself in stomach 2 with a framein gun 2in nails an was 15 feet in the air if anyone can guide me in the right directions i thank u so much……