04/20/2026
DENIALS - INSURANCE DELAYING CARE
One of my patients switched his insurance recently. He has Type 1 diabetes, an autoimmune condition since childhood, where his body does not create insulin. He needs insulin, a continuous glucose monitor, and an insulin pump to properly manage his blood sugars.
His new insurance no longer covered the continuous glucose monitor (CGM) brand that he uses to pair with his insulin pump - he was forced to switch to a different CGM. The new CGM that is covered under his new insurance caused an error with his current insulin pump, thereby wasting it. I sent in a refill for his insulin pump, but the pharmacy was unable to fill it because it was too early to refill, according to his insurance.
He called his insurance to explain the situation. Per the insurance company, a prior authorization request needed to be completed for his insulin pump, even though it has been approved and covered by them in the past. They faxed me a form that I completed and faxed back to them. Hours later, I received a reply stating that my request was denied.
In their reply, it was listed that my patient has Type 2 diabetes, and did not meet the insurance company's criteria for coverage of an insulin pump. The reply had several options for me to appeal this decision, the first option being that I could call the insurance company at ###-###-###X.
I was unclear how the insurance company determined that my patient has Type 2 diabetes when all of the supplies that I sent in were placed under the diagnosis codes for TYPE 1 DIABETES. I called the number listed on the options for appeal.
The first rep transferred me to a second rep, who then informed me that she could not initiate an appeal over the phone and I had to fax a form to the insurance company. If that was the case, why did they list calling this number as the first option for appealing the decision??? She did not know, but she asked me for my fax number to fax another form to my office.
I asked her how the insurance company arrived at the decision to deny my patient's necessary diabetes supplies, explaining to her that TYPE 1 DIABETES requires use of an insulin pump to properly manage the disease? She responded that the prior authorization form that I faxed in did not include chart notes. I pointed out to her that the form I received from the insurance company had one prompt which I responded to. Nowhere on the form did it ask for chart notes, ICD10 codes, or even a signature from me. I completed the one prompt as directed. She noted that the form they sent me was not the correct form anyway and that I needed to send in the form that she will be faxing me soon.
To summarize, the insurance company decided that my patient needed a prior authorization for his insulin pump that they previously covered, because he was requesting an early refill. They sent me the wrong authorization form. When I completed and sent back the form, instead of contacting me for more information or sending me the correct form, they assumed and gave my patient an incorrect diagnosis, then denied the prior authorization. It should be noted that in their denial letter, they had my office phone number and fax number listed. They could have contacted my office but chose not to.
At this point, I am livid!!! This is the kind of BS that creates a hostile work environment for all healthcare workers. This creates unnecessary stress and delays in care for patients. Delays in care such as these can lead to ER visits, hospitalizations, and death. INSURANCE IS SUCH A SCAM.
