Ask Dr. Hirsch: Insurance Coverage for Insulin Pump

Q:  Why do I have to prove to Medicare that I am a diabetic before they will pay for an insulin pump?  I have taken educational classes and applied for a pump, but was unable to satisfy the criteria for coverage because my C-peptide is too high (whatever that is).  I am currently taking Lantus^® twice daily and Novolog^® at each meal, but feel that the pump would make my control better and my life easier.  Is there a different course of action I should take?

A:  Insulin pumps are expensive and although many (but not all) people like them, they require a lot of effort on the part of the person using them. Pumps may initially cost up to $6,500.1 In addition, there is a monthly cost for supplies.  Medicare’s policy is to provide coverage for people who will get the most benefit from the pump - those who no longer produce their own insulin.  This includes people with type 1 diabetes and those with type 2 diabetes who have, over time, lost the ability to make insulin.2

Since you are taking insulin for your diabetes, it is very difficult to determine how much of the insulin in your blood comes from your pancreas. However, there is a way to do this - the C-peptide test.  C-peptide (short for connecting peptide) is a protein made when the islet cells make the initial, storage form of insulin, called proinsulin. Proinsulin is split into equal amounts of insulin and C-peptide when the pancreas releases insulin into the blood.  The C-peptide is also released at the same time. 

Since there is one C-peptide molecule for each insulin molecule, C-peptide levels serve as an accurate, indirect measure of the amount of insulin the body makes.    A normal C-peptide level is usually 0.5 to 2.0 nanograms per milliliter (ng/mL).  A level less than 0.55 ng/mL “proves” to Medicare that a person is not making enough insulin.  It is best to have the test performed when you are in a fasting state (first thing in the morning) when your insulin levels will be low. Your doctor may ask you to not take your evening dose of Lantus the night before the test. Your blood sugar should be measured at the same time as the C-peptide, too.

Medicare recognizes that the successful use of an insulin pump requires proper self-management skills.  In order to qualify, you also must:

• Complete a diabetes education program
  
  
• Inject insulin at least three times a day for the past six months
  
  
• Know how to adjust your mealtime insulin doses
  
  
• Test your blood sugar at least 4 times a day for the past two months
  
  
• Have a medically-documented need for a pump, such as an A1c over 7%, repeated hypoglycemia, wide fluctuations in blood glucose levels, or wake-up readings over 200 mg/dL.

These requirements may seem strict, but they do make sense.  Many people with type 2 diabetes find that they can achieve excellent control and flexibility with the kind of “basal/bolus” insulin program that you are using.  This type of program comes closer to the body’s normal insulin production better than a one- or two-shot-a-day regimen.  A basal/bolus program includes one or two injections a day of long-acting “basal” insulin, along with shots of short- or rapid-acting insulin at mealtimes that are matched to the amount of carbohydrate that is eaten. 

Research has shown that basal/bolus insulin therapy is generally just as effective as insulin pumps in achieving the level of diabetes control recommended by the American Diabetes Association (A1c  less than 7%)3 – what is really important is for patients to do frequent self-monitoring of blood glucose and knowing how to manage their diet, exercise, and insulin dosing.

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Laurence J. Hirsch, MD Worldwide Vice President of Medical Affairs, BD Diabetes Care Dr Hirsch graduated from the University of Rochester and then attended Harvard Medical School.  He is board-certified in Internal Medicine and in Endocrinology/Metabolism. Prior to joining BD, he was Assistant Professor of Medicine at Northwestern University, and spent more than 17 years in various roles in clinical drug development at Merck.