Diabetes denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bone density study. According researchers guidelines, bone density screening is recommended for postmenopausal women under age 65 with one risk factor. The detection of subclinical vertebral fractures using dual-energy x-ray absorptiometry (DEXA) vertebral fracture assessment is well established across current medical literature as results may alter clinical management. Recommendations for postmenopausal women over age 50 may include fracture, height loss, or glucocorticoid treatment. Other criteria include osteopenia and two or more of the following: being aged 60 to 69 years old, self-reported nonvertebral fractures, height loss, and chronic diseases associated with an increased risk of vertebral fractures.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a continuous glucose monitoring system. Both the medical literature and the submitted documentation support the medical necessity of the requested CGM system. In 2016, the American Association of Clinical Endocrinologists published a consensus statement favoring the use of CGM on patients with diabetes. The statement indicates that CGM improves glycemic control and reduces hypoglycemia. Expanding CGM coverage and utilization is likely to improve the health outcomes of people with diabetes. CGM alerts patients to impending or actual low or high glucose values and thereby facilitates prompt action and prevention of hospitalizations. Multiple studies cited in the statement have documented the superiority of CGM in improving HbA1c levels by decreasing hypoglycemia and hyperglycemia.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Long-term acute care hospital (LTACH) services. LTACH level care is intended for patients who require care that is more medically complex than can be provided at lower levels of care, such as inpatient rehabilitation, or SNF levels of care. LTACH level of care includes provision of chest tubes, extensive wound care, stable cardiac drips, multiple intravenous antibiotics, hemodialysis, prolonged intravenous therapy, total parenteral nutrition, tracheostomy care, ventilator weaning, and frequent imaging and laboratory testing. In general, more than one of these treatments is being provided at the LTACH level of care.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility care. Admission to a skilled nursing facility is appropriate for patients with conditions that require observation, evaluation of treatment plans, and updating of orders by a physician, as well as constantly available skilled nursing services. Patients require skilled nursing services, including wound management, tracheostomy care, bowel and bladder training and tube feeding, and administration of intravenous (IV) medications or medications that cannot be self-administered safely. Patients also require skilled nursing observation, including regular monitoring of vital signs, skin in the setting of wounds, and intake and output.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving diabetes, then check the rights and deadlines that apply to your plan.