Diabetic Neuropathy 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 MiniMed 670G insulin pump. Findings: The physician reviewer found that the Medtronic MiniMed 670G system was approved by the U.S. Food and Drug Administration with the following description: “The Medtronic MiniMed 670G system is intended for continuous delivery of basal insulin (at user selectable rates) and administration of insulin boluses (in user selectable amounts) for the management of type 1 diabetes mellitus in persons, fourteen years of age and older, requiring insulin as well as for the continuous monitoring and trending of glucose levels in the fluid under the skin”. The system is the closest to an automated closed loop system device for insulin delivery in the management of diabetes mellitus type 1.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continuous glucose monitor (Freestyle Libre 3). Unlike conventional glucose meters, which provide a snapshot of the blood glucose value during testing, continuous glucose monitoring technology supports diabetes management by providing semi-continuous information about glucose levels. Recent continuous glucose monitoring systems have moved beyond mere blood glucose monitoring by providing real-time and predictive glycemic data. The increased frequency of glucose monitoring is associated with decreased hypoglycemia and increased glycemic time in range, which correlates with improved A1C.

Where the denial was upheld

Findings: The physician reviewer found that a patient has requested authorization and coverage for extracorporeal shockwave therapy (ESWT). Although the literature supports ESWT as beneficial for reducing pain and improving sensory function in diabetic patients with confirmed neuropathy, the records in this case document only bilateral foot pain and diabetes with elevated hemoglobin A1c and estimated average glucose levels. There are no objective physical findings or diagnostic tests demonstrating neuropathy. Without such evidence, ESWT is not clinically indicated. Accordingly, the requested ESWT is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested procedure is not medically necessary for the treatment of the patient's medical condition.

A female enrollee requested in-home occupational therapy and in-home physical therapy for medical treatment of her medical condition. Findings: The physician reviewer found that for those with diabetic neuropathy and gait disorders, aerobic exercise training can provide some benefit in function. In this case, the patient has undergone significant home physical therapy and she has progressed to ambulating short distances at stand by assistance. She was discharged from her treating home physical therapist and is independent with self-care. Further improvements in endurance can be achieved as tolerated with custodial level supervision and assistance from caregivers. No marginally significant improvements in outcomes or clinical course would be expected with further home therapies beyond an independent exercise program with custodial level supervision and assistance.

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