Medicare Insulin Pump Requirements

I get a lot of searches from people looking for the Medicare c-peptide requirements so I thought that I would add a post with what those requirements are here.  I have also seen

some “misinformation” being posted on messages boards.  The most reliable information is directly from the source itself so I am putting the link to the CMS manual that covers insulin pump requirements.

Please note that besides either meeting Criterion A or B, you must meet the c-peptide requirements.  I recently saw someone post that anyone already having a pump would be able to continue pumping because Criterion B includes those already pumping.  However, the key words under the General CSII Criteria are “In addition to meeting Criterion A or B above,” so the c-peptide requirement must be met regardless of whether you meet the other requirements or not.

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Medicare and Insulin Pumps

Because I am on disability, I am also on Medicare.  I have a Medicare supplemental plan and they follow Medicare guidelines.  Prior to getting the pump, I had to get a C-peptide test to show that I was not producing insulin.  I am coming up on my 27 year anniversary in January and I have no idea if I ever had a C-peptide done back in the early days, but I had to have one in order to get the pump.  I am not sure if you want to say that I passed or flunked since I only had a trace amount of insulin being produced, but I was able to get my pump.

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Insurance Red Tape

After getting the Dexcom, I started the process to get a pump.  That process actually was not that bad.  My doctor was reluctant to sign the paperwork, but I managed to convince him.  Because I have a Medicare Advantage plan, I had to have a fasting C-peptide test to prove that I had little to no insulin production.  Medicare does not pay for pumps for Type 2 diabetics.  I am not sure whether you want to say I passed or flunked that test.  My test came back as <0.1 with the range being 0.9 – 4.3.  The lab repeated the test with a different range and that came back as <33 with the range being 297 – 1419.  I guess it is official – I am a Type 1 diabetic!  I already knew that 26 years ago, but now I qualify for a pump.  Three weeks and two days after I went to the lab for my C-peptide test, the supply company called to say that they had approval to send the Animas Ping.

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