Pain pump PTM and insurance

Hi Mike & welcome to the forum. The PTM's come with the pumps, it's a package deal. At the time of implant it is in the box with the pump, sometimes the box is given to the patient or the dr gets it to give to the patient. If you have your model number of your pump, when it was implanted Medtronics can tell you if you had a PTM. Sadly, there are stories of drs not telling the patient they have a PTM. We have had members here that had no idea their pump came with a PTM & they called Medtronics & was told yes, a PTM was included & to contact their dr! They got their PTM's once they questioned the dr.

Your new dr should have a staff member that gets approvals, this is the person that needs to be contacting Medicare with the proper documentation. I know many years ago private insurance would not pay for the PTM separately. Years ago they cost $1,000, no telling what they cost now.

WhiteBeard, not all drs will allow their patients to use a PTM, which is ridiculous. Many patients are not aware of what a PTM is, let alone know it comes with their pump. We are still seeing new members with pumps come here that have no idea what one is & the PTM is at their drs office.

Just talked to Medtronics again. They said that the PTM is only included in the kit if the prescribing doctor specifically requests it. They do not have me registered as having one, meaning the PM doctor never prescribed one for me, and never received one for me. As a result, neither I nor my PM doctor can claim that I lost it and then seek a replacement. Unless I can get insurance to cover it, I'm out of luck.

This is about the 30th phone call I've made in 3 days and while I'm closer to an answer, it's not likely an answer that I want to hear.

Thanks,
Mike

Well Mike if you can afford the 400 dollars and your current PM is willing to get you a PTM from the company for you, I personally think I would jump at the chance to get it!!! Your PM will program it to the number of bolus doses you can give yourself in a 24 hour period and the waiting time between each bolus dose and the amount each bolus dose is! When I first got mine it was programed for a max of 10 bolus doses in a 24 hour period with a 2 hour waiting period between doses, after my second refill he changed it to only one hour between bolus doses but left the max at ten bolus's per 24 hour period. I've nevered came close to using all ten bolus doses in a 24 hour period, so when I went up for my last refill on Oct 31 he changed to a maximum bolus doses in a 24 hour perion to eight.

When they refill and program or reprogram your pump, they can down load from your pump how many times you used your PTM in (for me a 6 month period as that is how often I get my pump refilled) and how many times when you used your PTM it successfully gave you the bolus dose and how many time it rejected it because of not waiting the proper interval or what ever was the reason!

It sounds like your current PM is really good, and if he thinks the PTM would really help you, and yes it is unfortunate that your previous PM didn't order them and use them togethet, and that now you will have to pay out of pocket for it!! But....if you can afford it,...... I personally think it would be worth getting!! I guess I am just fortunate that my PM includes the PTM as part of his patients pain management! For me I had no additional expense with it, What Medicare didn't cover TriCare for Life did!

Anyway just my thoughts about it. Good Luck to you Mike

White Beard

Mike, have you explained the secondary insurance has paid for medical items that Medicare would not? I am asking because perhaps this dr is thinking this is a supplemental policy to Medicare, which it is not. Wow, all his office staff has to do is submit the paperwork & they will say yes or no on the authorization. I can understand your frustration, the dr is not looking out for your best interest. This is not like the dr has to this himself, that is what his staff is for.

I am sorry the dr has put you in this situation.

If you can get the Dr's office to give you the itemized bill with the detailed charges and procedure codes, you can then submit it to your secondary insurance without the Dr's staff having to deal with the insurance at all. I don't know if that will help you in the slightest, but it's at least one other option to try.