Type 2 Diabetes Mellitus denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Mounjaro. A researcher explains, “Tirzepatide (Mounjaro™) is a single molecule that combines dual agonism of glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptors. Native GIP and GLP-1 are incretin hormones that stimulate insulin secretion and decrease glucagon secretion. GIP also plays a role in nutrient and energy metabolism, while GLP-1 also delays gastric emptying, suppresses appetite, and improves satiety. Eli Lilly is developing tirzepatide for the treatment of type 2 diabetes mellitus (T2DM), obesity, cardiovascular disorders in T2DM, heart failure, non-alcoholic steatohepatitis, obstructive sleep apnea and for reducing mortality/morbidity in obesity.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Ozempic and/or (2) Dexcom G6 continuous glucose monitor (CGM) system. Researchers report that diabetes, a chronic disease that is often accompanied by multiple comorbidities and health complications, is the seventh leading medical cause of death in the United States. The U.D. Food and Drug Administration (FDA) approves using Ozempic (semaglutide) to lower blood sugar in patients with type 2 diabetes mellitus. Researchers report that clinical research showed that when Ozempic was added to other standard therapies for patients with a history of type 2 diabetes mellitus, these patients saw a substantial decrease in their A1c levels. The A1c cut-off goal for the trial was set at greater than or equal to 7.0.

Where the denial was upheld

Findings: The physician reviewer found that the patient has requested authorization and coverage for medically tailored meals. The Food is Medicine Coalition describes medically tailored meals as medically appropriate meals delivered to the homes of individuals living with complex, severe, or chronic illnesses who are too sick to shop or cook for themselves. These meals are supervised by registered dieticians and tailored toward the specific nutritional needs of eligible recipients. Nutrition and diabetes are intricately intertwined. Authors report that the foundation of medical nutrition therapy for type 2 diabetes is to achieve glucose, lipids, and blood pressure within the target range to prevent, delay, or manage microvascular and macrovascular complications.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mounjaro. Diabetes mellitus is a common, albeit potentially devastating, medical condition that has increased in prevalence over the past few decades to constitute a major public health challenge in the twenty-first century. The mortality rate for patients with diabetes is one and a half times higher than for individuals without diabetes. Tirzepatide (brand name Mounjaro), a glucose-dependent insulinotropic polypeptide (GIP) receptor and glucagon-like peptide-1 (GLP-1) receptor agonist, is approved by the U.S. Food and Drug Administration (FDA) for the treatment of type 2 diabetes mellitus, along with diet and exercise, based on clinical data demonstrating that tirzepatide is superior to placebo in improving hemoglobin (Hb) A1C levels.

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