Type 2 Diabetes denials in California external review
In the California DMHC record, independent physician reviewers decided 190 published external-review cases involving type 2 diabetesand overturned the plan’s denial in 73.7%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for type 2 diabetes
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 182 | 75.3% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 8 | 37.5% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for WeGovy 2.4 mg auto-injection. A review of the record indicates that the patient has been diagnosed with type 2 diabetes, hyperlipidemia, and obesity. The provider noted the patient has been undergoing treatment with WeGovy for one year and has lost 35 pounds. The provider has recommended WeGovy. The Health Plan indicates that the requested medication is not medically necessary for the treatment of the patient’s medical condition because her body mass index (BMI) is less than 40 without other health problems due to the weight or has a BMI less than 35 with other health problems due to the weight. The issue is whether WeGovy 2.4 mg Auto-injection is medically necessary to treat the patient’s medical condition.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mounjaro Solution Pen-injectable 5 mg/0.5ML (once a week).The use of glucagon-like peptide-1 (GLP-1) receptor agonists for the treatment of type 2 diabetes is supported by guidelines from both the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) (Blonde, L., et al.; ElSayed, N., et al.). These guidelines recommend GLP-1 receptor agonists as a second-line or adjunctive therapy for individuals with type 2 diabetes who are not adequately controlled on metformin or for whom metformin is contraindicated. GLP-1 receptor agonists work by increasing insulin secretion, reducing glucagon secretion, and slowing gastric emptying.
Where the denial was upheld
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Mounjaro pen. The American Association of Clinical Endocrinologists (AACE) guidelines support the use of glucagon-like peptide-1 (GLP-1) receptor agonists for the treatment of type 2 diabetes. Likewise, the American Diabetes Association (ADA) guidelines support the use of GLP-1 receptor agonists for the treatment of type 2 diabetes. These guidelines recommend GLP-1 receptor agonists as a second-line or adjunctive therapy for individuals with type 2 diabetes who are not adequately controlled on metformin or for whom metformin is contraindicated. GLP-1 receptor agonists work by increasing insulin secretion, reducing glucagon secretion, and slowing gastric emptying.
Findings: The physician reviewer found that the patient has requested authorization and coverage for Mounjaro. The American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) guidelines on the management of type 2 diabetes support the use of glucagon-like peptide-1 (GLP-1) receptor agonists. These guidelines recommend GLP-1 receptor agonists as a second-line or adjunctive therapy for patients with type 2 diabetes who are not adequately controlled on metformin or for whom metformin is contraindicated. GLP-1 receptor agonists increase insulin secretion, reduce glucagon secretion, and slow gastric emptying. They also have the added benefit of causing weight loss and helping to reduce cardiovascular risk in individuals with type 2 diabetes.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 2 diabetes, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY