Diabetes Mellitus Type 2 denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Dexcom continuous glucose monitoring system. The Health Plan has denied this request indicating that the requested device is not medically necessary for management of the enrollee’s medical condition. Findings: The review of the medical literature supports the use of CGM system in diabetes mellitus type 1 and 2. Appropriate use of real time CGM improved glycometabolic control in type 1 patients. The effects of CGM were more evident in patients under multiple daily insulin treatment, compared with insulin pump therapy. Glucose variability, in addition to glycemic control, was improved in compliant diabetic patients (Tumminia, et al).

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for medically tailored meals. The requested medically tailored meals are supported as medically necessary for the treatment of this patient. The records indicate that the patient has multiple complex medical conditions which are severe including hypertension, congestive heart failure, and diabetes mellitus type II. In addition, the patient has significant edema requiring fluid and electrolyte management beyond that required for these diseases. The current guidelines for hypertension, congestive heart failure, and type 2 diabetes, recommend specialized dietary treatment, which can have a significant impact on the disease. Controlling sodium intake, carbohydrate intake, and calorie intake to stay within these guideline recommendations is complex.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a continuous glucose monitor (CGM). CGM detects glucose variations, time in glycemic target, and time in hypoglycemia. These metrics have been shown to enhance a patient’s self-management of diabetes. In a study by Ida and colleagues aimed to investigate the effects of CGM devices in patients with type 2 diabetes mellitus, the authors found that the CGM group exhibited significantly lower HbA1c levels and spent less time with hypoglycemia. This patient’s records indicate that he has a diagnosis of diabetes of recent onset. However, there is a lack of documentation of a thorough evaluation and discussion on the goals of therapy with his primary care provider or nutritionist.

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for a FreeStyle Libre 3 continuous glucose monitoring (CGM) system (monitor and sensors). The American Diabetes Association and the American Association of Clinical Endocrinology recommend use of CGMs for diabetes management in adults with diabetes who use insulin. In this case, the patient presents with diabetes mellitus type 2. The patient’s diabetes is managed with tirzepatide. The records do not demonstrate that the patient is taking insulin. Tirzepatide does not raise the risk of hypoglycemia in a meaningful way. A CGM is not recommended by the medical guidelines except for patients who take insulin.

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 type 2, then check the rights and deadlines that apply to your plan.