Diabetes Mellitus denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Freestyle Libre - continuous blood glucose monitor (CGM).Findings: The physician reviewer found that A CGM system is one of several devices approved by the U.S. Food and Drug Administration (FDA) that record blood sugar levels at repeated intervals throughout the day and night. Olczuk and Priefer note that self-monitoring of glucose allows patients with diabetes mellitus to take control of their disease and thus directly affect the outcomes related to it. Zheng and colleagues report that CGM systems may be clinically valuable due to their accuracy and convenience and may promote glycemic and weight control, helping to reduce the risk of hypoglycemia and hyperglycemia.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for a Dexcom G6 glucose monitoring system. Studies note that self-monitoring of glucose allows patients with diabetes mellitus to take control of their disease and thus directly affect the outcomes related to it. Studies note that while finger-prick devices have commonly been used to monitor blood glucose, continuous glucose monitoring (CGM) systems have recently been refined and improved for home use. Studies report that CGM systems may increase the effectiveness of glucose control and minimize hypoglycemia risk. In a comparison of the Dexcom and FreeStyle Libre CGM systems, Link and colleagues found that the Dexcom G5 Mobile generally appeared to be more accurate in measuring blood glucose.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for a Dexcom G7 continuous glucose monitoring (CGM) system.Continuous glucose monitoring (CGM) technology has evolved into an important tool to support diabetes management. Unlike conventional glucose meters, which provide a snapshot of the blood glucose value at the time of testing, CGM systems provide semi-continuous information about glucose levels. CGM systems can be a good option for patients with inconsistent or confounding glycemic control, who desire engagement in their own disease management, or whose treatment plan puts them in danger of hypoglycemia.

Nature of Statutory Criteria/Case Summary: An enrollee has requested Trulicity and Vascepa for treatment of his hypercholesterolemia and diabetes mellitus. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications. The records document diabetes and hypertriglyceridemia. In this circumstance, treatment with lifestyle changes and medication is appropriate and recommended by current guidelines. The patient has requested coverage for Vascepa. However, the Health Plan denied this requested due to an inadequate trial with two of the following medications: gemfibrozil (Lopid), micronized fenofibrate or Niacin. These alternative medications are effective in the treatment of hypertriglyceridemia, and it is medically appropriate to try these drugs prior to Vascepa.

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 mellitus, then check the rights and deadlines that apply to your plan.