Insurance Blues

So, we’ve been trying to get Aetna to approve a MySentry from Medtronic and no matter what we tell them they deny us a new insulin pump. What they can’t seem to understand is that a MySentry is not a new insulin pump or a new Continuous Glucose Monitor (CGM) it is something that works with the pump and CGM. It would relieve a lot of the worry that Tony and I deal with every night. Here’s what it does: It sends the signal from TJ’s CGM and Pump to an alarm clock sized receiver in our bedroom. This could save TJ’s life! If TJ’s sugars drop too low at night while he’s asleep he could die; a very scary fact of diabetes. Tony and I have to check him at night to make sure he’s not too low and if he is we wake him up to give him sugar.

Right now we have a baby monitor in TJ’s room (really we’ve never taken it out of his room from when he was a baby—just bought new ones as the old ones die or get too buzzy) Unfortunately if TJ sleeps on his pump we don’t hear the alerts through the monitor (and he seems to like sleeping on his pump!). Frequently we wake up to check on him only to find out that it’s been alerting for hours and we didn’t hear it. The MySentry would alert in our room and show us on the screen what his sugars are at (based on info from the CGM)

The problem is the MySentry is something new (just came out this year) and there is no medical code for it. Medtronic bills it under a miscellaneous code which Aetna keeps interpreting as a new insulin pump (even though there is a specific code for insulin pumps!) We’ve appealed and I just found out today that they denied our appeal because TJ doesn’t need a new pump. I agree he doesn’t but he does need the MySentry and I don’t know how we will be able to afford it if the insurance doesn’t cover it.

This is the letter I submitted to Aetna as part of the appeal process, you tell me: Does it sound like we want a new insulin pump? Or did they not even bother to read the letter?

I probably sound very ungrateful and I’m not. I truly appreciate everything that Aetna has already covered for TJ. They are the reason he has an insulin pump and a CGM (they covered both at 100%)and we couldn’t keep TJ in range nearly as well as we do without those. I also think I could live with them saying it’s not medically necessary (It would make me very sad and I would have to find a way to come up with about $2000 to pay cash for it) but I could understand. What I can’t understand is why they can’t look at what it is before denying it.

It’s funny I thought once they read the letter there’s no way they could claim it’s not medically necessary but they still think we were asking for a new pump, so maybe it’s not as clear as I thought. You be the judge! Our Medtronic Rep resubmitted in the hope that we’ll get a different team to review it and actually see what it is we are asking for. Please pray that they approve it and before the end of the year! J

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