This post is a sneak peek from a chapter in my book Pumping Kids, a Step by Step Guide to Insulin Pumps. Sign up here to get the first chapter free and be notified when it is available. It is also available for pre-order on Amazon.
Many people are unsure about how to get an insulin pump. You don’t just go to the doctor’s office and get one. The pump must be ordered and will be mailed to you and then pump training will be scheduled. Once you and your doctor decide on a pump, the pump can be ordered.
I know I didn’t have a clue so I want to lay out the process. It’s more time-consuming than you would think. It can be a one to two month process. Note that the process I am referring to is specific to the United States and insurance companies.
Depending on your insurance, the requirements can be different. Here are some things that may be needed by your insurance. Don’t worry, the pump sales representatives are here to help you with this process and they get much of the paperwork completed.
- Medical necessity form, may be referred to as a CMN or certified medical necessity letter. The pump reps will get this completed and signed by your child’s physician.
- On the CMN, you may be asked questions such as whether you have had previous diabetes education and the answer needs to be “yes,” how often your child is checking blood sugars and the answer needs to be at least 4 times a day, how long your child has been diagnosed (some insurances require over 6 months), presence of high and low blood sugars, whether your child has been hospitalized in the last year, and whether any diabetes complications are present.
- Last two medical chart notes. The pump representatives will request these from the physician. In these chart notes, there may need to be documentation about how many times bg is being checked, and the insurances may note anything stating there is noncompliance to the medical plan and deny a pump. Some insurances are picky about what can and cannot be in the notes in order to approve a pump.
- Checking blood glucose at least 4 x day. Some insurances require a thirty-day blood sugar log which must show bg being checked at least 4 times a day. This can be a written log or a meter download. If you are also ordering a continuous glucose monitor, many insurances are looking for two readings less than 50.
- Labs including A1C and possibly c-peptide. Some insurances require a specific blood test called a c-peptide. This is not routinely drawn with three-month labs and your child may need to have blood work drawn if one is not on file in the medical chart.
- Signed AOB (Assignment of Benefits). The pump company must have this signed which authorizes them to speak with your insurance to get benefits. The form is available online and from the pump representatives.
To get started ordering a pump, you can either contact the sales representative yourself, your doctor’s office may have paperwork for you to sign that they send to the rep, or you can complete online paperwork.
Once you have completed paperwork, you should receive a call from the pump company. Depending on your insurance, the pump company may be able to process the order or they may need to send the order to another company called a DME or durable medical equipment company. The pump company will tell you if the pump order will come through a DME company. Know that this is normal and you will hear from another company that will complete the order.
Once the company verifies your insurance benefits, they will review costs with you. They will send in paperwork to your insurance company and wait on approval. You should be kept in the loop on the process but it may take a while, even a month. If your insurance denies the pump, the pump companies work with you to determine why it is denied and they can appeal the process.
When thinking about costs, the cost includes supplies. Ask whether the order is for a 3 month supply or a 1 month supply. Some insurances require that supplies be ordered monthly. Ask the company if you can be on automatic shipment, which means the supplies will be automatically sent, your insurance will be billed and if you have a cost, the charge will be charged to a credit card. Auto ship makes life so much easier!
The insulin does not come with the insulin pump or supplies. The insulin will need to be acquired from your pharmacy or mail order just as you are currently getting insulin. If you use insulin pens, the prescription will be changed to vials, which may sometimes cost less.
Once the pump is approved, the company will call you to set up payment and ship the pump. Some companies offer payment plans if you ask. The pump and supplies will be mailed to your home or the doctor’s office.
Once your pump is shipped, the pump company’s clinical manager who does training is notified. The clinical manager will contact you to schedule training. Some physician offices do their own training, in which case you may need to contact your doctor’s office to schedule an appointment.
Not sure how pump work? Here’s some additional posts you might find helpful: