WESTERVILLE, Ohio, July 28 /PRNewswire/ -- All doctors recommend diabetic patients control their glucose level, but how can they do this while preserving a normal lifestyle? By using an insulin pump and carbohydrate counting, a diabetic can maintain precise glycemic control and lessen the long-term effects of their disease. Still, because of the cost of insulin pumps and their supplies, health insurers often turn to independent review organizations (IROs) to decide their medical necessity.
"Using evidence-based criteria, IROs review the medical necessity of insulin pumps for health plans," said Seana Ferris, President of NAIRO, a trade organization of IROs. "They must weigh improved glycemic control, patient pump management, patient knowledge and lifestyle against the long-term cost of a diabetic's health care before approving a $6,000 pump that also requires hundreds of dollars a year for supplies."
When Insulin Pumps are Medically Necessary
Replacing injections, a pump delivers insulin 24-hours a day through a catheter under the skin. With a pump with carbohydrate counting, a patient can adjust insulin levels accurately for food intake and elevated or low blood sugar. "Health plans often cover pumps when they improve a patient's diabetic care and provide better control than multiple daily injections," said David Sand, M.D., Chief Medical Officer of an Ohio IRO, HMS-Permedion, and a pump-wearer. "They routinely cover pumps for patients with type-1 diabetes. The hope is that better glucose control lessens end-organ damage, which can benefit type-2 patients also."
Health plans may ask an IRO review the medical necessity for an insulin pump when daily doses of insulin don't achieve tight glycemic control and the hemoglobin A1c rises above the recommended seven percent set by the American Diabetes Association, or when hypoglycemia continues despite adjusting insulin doses. "Programming the pump to adjust basal insulin delivery rates and boluses throughout the day allows for more precise glycemic control, achievement of target HbA1c levels, and prevention of long-term complications," Sand said.
Demands Patient Skills
Sand explained that a concern of health plans about insulin pumps is the patient's ability to manage one. A healthcare provider team, including an endocrinologist and diabetes nurse educator, teaches the patient how to insert and change the catheter, set and adjust the basal rate and calculate boluses.
"While glucose monitoring is important for any diabetic, it's even more so for pump users who must adjust their boluses regularly for food intake and activity," Sand said. "Besides, pumps aren't an excuse for dietary indiscretion. Patients must learn carbohydrate counting to deliver correct insulin boluses at mealtimes."
NAIRO works to promote the value and integrity of the independent medical review process, as an integral part of improving U.S. health care. Its members embrace an evidence-based approach to medical review for resolving coverage disputes between enrollees and their health plans. For more information, visit www.nairo.org.
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