Medicare Denials

Medicare has not approved my pump supplies or insulin which they cover as a DME. My Supplier, Advanced Diabetes Supplies, has sent them quite a bit of paperwork, but the appeals were denied too. I know part of it is because I already had the pump from another insurance provider and Medicare does not recognize it because they didn’t approve it. ADS keeps reassuring me they’ve sent everything in, including the proof I own a pump, and it is now being sent to a higher level/judicial action. Meanwhile it seems I can’t do anything and have to hope ADS can get this settled. I started on Medicare in February and so far no insulin or pump supplies have been paid. I’m confident Medicare has made it so difficult with their crazy documentation requests, but I am disappointed the supplier is not on top of all the crazy demands. My questions for Medicare folks on pumps: 1) Is Lispro covered as a DME or are there only specific insulins covered as a DME? I’m told all are covered, but I can’t find that in writing
2). If you’ve experienced this same problem (having the pump prior to joining Medicare and Medicare saying there is no proof you are on a pump) and have any advise, please share. Thank you!

Hi Mary. Are you a Type 1? If you are have you seen your doc since enrolling in Medicare and had bloodwork done that included the C-Peptide test?

Tip: When talking about insulin coverage say “Part B” instead of DME. Part B covers lots of stuff.

I was looking for an answer to which insulins are covered for pumps so I’m glad you asked. I look forward to seeing what some of the more experienced people have to say. Best as I could figure out it is limited by your Part D formulary even though its billed to Part B.

Sorry to hear this. Its pathetic how the federal government fails at providing basic support for citizens. Couldn’t imagine how awful and expensive our healthcare system would be if they took it over. Unfortunately they continue to want full control over it…

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As long as you bought the pump, it does not matter what insurance company covered it. You MUST tell them you own the pump. Now if you do not own the pump, then yes Medicare will deny the supplies for it. You must own it.

Thank you for all of your replies, especially the Decision Memo information. Update:
Yes, I am Type 1 for 58 years. I use Lispro. I did provide an invoice and packing slip for the pump. I was never told exactly what info they needed as proof for the pump, but the provider assured me they had everything needed. .Further update: After calling the number on the Medicare Notice of Hearing and Appeal for the original insulin order, I was finally told Medicare needed my EOB for the pump and the original physician’s order and that just telling them I had a pump or sending them the invoice was not adequate. Fortunately I was able to find the original EOB online as I was still in the old insurance system. I sent it to Medicare and the provider. Then 2 days later I received a notice from Medicare that they approved the appeal for my July insulin order as they now recognize I have a pump. That letter was sent in January, after two appeals. I am HAPPY Medicare now recognizes my pump. I assume from now on there should be no problem though the Hearing with the Judge is still scheduled as that claim was for an earlier claim.

So lesson learned: Save your EOB for insulin pumps. Thank you for your comments and good information.

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Great advice for almost anything, especially health coverage!