Type 1 Diabetes 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 Ozempic. Type 1 diabetes is an autoimmune disease that may coexist with insulin resistance syndrome, which leads to obesity and metabolic syndrome, resulting in type 2 diabetes when associated with hyperglycemia. This condition is known as double diabetes. Researchers observed that “Double diabetes seems to be an independent and important risk factor for persons with type 1 diabetes mellitus in developing macrovascular and microvascular comorbidities.” In this case, the records indicate that the patient has coexisting type 1 and type 2 diabetes. The patient also has a diagnosis of obesity as evidenced by his body mass index (BMI) greater than 30 kg/m2, which requires treatment.

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

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mounjaro Soln Auto-inj 15 mg/0.5 mL.Type 1 diabetes is solely insulin-dependent. Most type 1 diabetic patients rely on multiple daily insulin injections to control their blood glucose. Intensive insulin therapy, typically through multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII) using insulin pumps, is generally required. Tirzepatide (Mounjaro) is a glucose-dependent insulinotropic polypeptide (GIP) receptor and glucagon-like peptide-1 (GLP-1) receptor agonist. The U.S. Food and Drug Administration (FDA) approved Mounjaro for treating patients with type 2 diabetes mellitus along with diet and exercise, based on data from clinical trials.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for automated insulin delivery for treatment of the enrollee’s diabetes type I. Fulfills Findings: The physician reviewer found that The requested device is considered investigational as long term studies are not available. There is not enough long term data to show that it is superior over other monitoring devices. At this time, the incremental benefit of automated closed loop control of insulin administration is unclear. There is currently no long term data available demonstrating health outcome benefits of such technology compared to other treatment methods, including multiple daily injection therapy and continuous insulin infusion therapy with or without a threshold suspend device with or without CGM.

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 type 1 diabetes, then check the rights and deadlines that apply to your plan.