If you have questions about the practices of your managed-care coverage, ask the experts at the state Department of Managed Health Care.
On the advice of my daughter's pediatric endocrinologist, we recently started the process of migrating her from an insulin pump she received in 2005 to a tubeless insulin pump called the OmniPod. This new pump will better regulate my daughter's fluctuating glucose levels, and that will help manage her Type I juvenile diabetes. We also think this pump would go a long way toward providing the 11-year-old with a more normal childhood. It would allow her to play sports without having to take off her insulin pump.
However, our medical group denied our request, which meant we had to appeal to our HMO. The HMO also denied our request and told us the reason was that the OmniPod is considered to be an investigational treatment. We disagree. The OmniPod system received clearance from the FDA in January 2005. Not only that, but it is significantly less expensive than the pump she is on now.
– J.S. in Antelope
Although FDA approval of a piece of medical equipment is an indication that the equipment can be considered safe, it does not mean a health plan must provide coverage for it. In this case, your health plan's denial was at least partially based on a lack of controlled studies validating the effectiveness of the OmniPod pump system. Consequently, the health plan considers this pump to be "investigational."
The Independent Medical Review, or IMR, program offered by the Department of Managed Health Care allows consumers to challenge a health plan denial if it is based on an experimental or investigational rationale. The case is sent to a doctor, or a panel of doctors in some situations, for a binding determination.
This process allows neutral reviewers to examine the case and its specific variables, and treat it as a unique situation. In your daughter's case, the reviewer found the OmniPod is a desirable alternative because there is no tubing to interfere with her ability to play sports – an important component of care in young patients with Type I juvenile diabetes.
The reviewer concluded that the requested OmniPod pump is medically appropriate for her, and that it is more likely to improve her compliance with the treatment program and control of her condition. Your health plan's original denial was overturned, and the health plan is required to authorize the OmniPod pump for her.
If you have had a request denied by your health plan and you want to find out if you qualify for a free IMR, log onto www.healthhelp.ca.gov or call the DMHC toll-free at (888) 466-2219.
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