Hypoglycemia denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that An enrollee has requested authorization and coverage for Dexcom G6 continuous glucose monitor system (including sensors, transmitters, and receiver). In this case, notes report diagnoses of hypoglycemia and Raynaud’s disease. The patient does not have diabetes. In an application for independent medical review, the patient reports having to test glucose levels using finger sticks several times daily. The patient reports that the use of finger sticks is challenging as Raynaud’s disease causes the patient's fingers to lack daily blood flow. The patient reports a history of dangerous hypoglycemia levels leading to a loss of consciousness. Hypoglycemia may occur in patients without diabetes due to multiple causes and is dangerous condition.

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with type 1 diabetes, hyperlipidemia, hypoglycemia, and left non-proliferative retinopathy. On 8/23/18, the patient’s hemoglobin A1c level was 7.4. In a report dated 1/24/19, the patient reported hypoglycemic episodes. His home blood glucose logs show frequent hypoglycemic events. The patient had been treated with Lantus and Humalog. On 2/5/19, the patient’s hemoglobin A1c level was 7.1. The patient’s provider adjusted his insulin doses to avoid hypoglycemia. The patient requested coverage for an insulin pump and continuous glucose monitor. The Health Plan denied the request and reported the requested equipment was not medically necessary for the evaluation and treatment of this patient.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a medical alert bracelet. This patient presents with a history of diabetes and hypoglycemia. There is a lack of medical literature supporting the use of medical jewelry for diabetes or hypoglycemia. The Health Plan correctly stated that the medical bracelet is indicated for patients with anaphylaxis or with dementia. This patient does not report a history of anaphylaxis or dementia. Furthermore, the patient’s risk of hypoglycemia is markedly reduced with his continuous glucose monitor. All told, the requested medical alert bracelet is not medically necessary for the evaluation of the patient. Final Result: The reviewer determined that the requested device is not medically necessary for the evaluation of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld.

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