Living with diabetes blog

Insulin pumps: Medicare coverage?

By Nancy Klobassa Davidson, R.N. and Peggy Moreland, R.N. October 19, 2011

This blog is the third in a three-part series in which we discuss Medicare coverage for diabetes supplies.

Medicare Part B covers insulin pumps worn outside the body — including the insulin used with the pump — for some people with Medicare Part B who have diabetes and meet certain conditions.

What are those conditions? You must meet either criterion A or B.

Criterion A
Criterion A states that you must:

  • Meet C- peptide or beta cell autoantibody lab test results requirement (blood test results that show that you make little or none of your own body insulin)
  • Complete a comprehensive diabetes education program
  • Have been on a multiple daily injection (MDI) program for six months, using at least three insulin injections a day
  • Provide documentation of blood glucose testing an average of four times per day
  • Meet one of the following: 1. Have an A1C greater than 7 percent, 2. Have a history of recurring hypoglycemia, 3. Experience wide fluctuations in blood glucose levels before meals or dawn phenomenon — an early morning rise in blood glucose or hormone levels
  • Experience severe swings in blood glucose levels

Criterion B
Criterion B states that you must have been using an insulin pump prior to enrollment in Medicare, and that you have documentation of testing your blood glucose four times a day during the month prior to Medicare enrollment.

Important details
In addition, it's important to note:

  • Coverage amount. If approved, you pay 20 percent of the Medicare approved amount after the yearly Part B deductible.
  • Provider requirements. The insulin pump must be ordered by a medical provider who manages multiple patients on insulin pumps, and you must be seen by this provider every three months.
  • Timing of prescription renewal. Before your yearly prescription has run out, you must be seen by your insulin pump provider in order for Medicare to continue paying for pump supplies. I have seen cases in which my patients didn't have an appointment with their provider, or the appointment got delayed or missed. Medicare wouldn't cover the supplies until that individual was seen by the provider. Meanwhile, the patient was stuck without supplies and was unable to use his or her insulin pump.

What are your experiences with insulin pumps and Medicare?

Have a good week.

Regards,

Nancy

Oct. 19, 2011