Type Ii Diabetes Mellitus: when insurers say no, reviewers often say yes

Where the denial was overturned

The patient is a 36-year-old male with diabetes mellitus type II, who is obese, insulin resistant and dyslipidemic. He appears to have been untreated from 2000 until July of 2005. In July 2005 the patient started on Actos tablets and Lantus insulin with initial improvement in his hemoglobin A1c from 12.2% to 11.5%. By September 2005 his A1c dropped to 9.1%. The patient was also noted to have postprandial blood sugars in the 180 mg range; significantly above the American Association Of Clinical Endocrinologists’ recommendation of 140 mg. Byetta injections of 5 mcg twice a day were added to his diabetic regimen by his endocrinologist. Within six weeks the patient reported fasting blood sugars of less than 100 mg and postprandial levels around 120-30 mg.

The patient is a 52-year-old female with type II diabetes mellitus, diagnosed about nine years ago. In July 2005 she was on Glipizide 10mg twice per day and Avandia 4mg twice per day and her HgbA1C was 9.8%. The record indicates the patient does not tolerate Metformin due to diarrhea, and she was started on Lantus insulin at 18 units. The patient’s weight was reported as 240 pounds. In December of 2005 her HgbA1C decreased to 8.5% and she had a weight loss of five pounds. At that time, she was started on Byetta 5mcg twice per day. In March 2006 the patient’s HgbA1C had decreased further to 7.1% and she lost an additional three pounds. In June 2006 her HgbA1C was down to 6.7%. The patient has requested reimbursement and continued authorization and coverage for Byetta.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient requested reimbursement and prospective authorization and coverage for shift care private duty nursing services. The submitted documentation does not support the medical necessity of the services at issue. A review of the record reflects that the patient has been receiving ongoing home health skilled nursing care primarily for the management of his type II diabetes mellitus. The patient is also noted to have a medical history of a left lower extremity amputation and localized swelling in the left lower limb. The record reveals that the patient requires supervision and assistance for mobility along with performing daily activities. The patient has been educated regarding his medical conditions and there is no indication of recent hospitalization.

The patient is a 32-year-old female with diabetes. The record indicates that she injects Lantus and Novolog insulin four times a day. The dose of both types of insulin is not documented nor is there documentation of any oral medications used to control her diabetes. The patient appears not to have long-term complications or hypoglycemic unawareness. The blood sugar log kept by the patient from August 2005 through November 05 shows close to adequate control. There are two morning blood glucose levels of 60 and a few of over 200. In May 2005 her hemoglobin A1C was 7.1%. In September 2005 the patient had a blood glucose of 311 recorded by the lab and her hemoglobin A1C was 9.2%. There is no recent hemoglobin A1C recorded.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for type ii diabetes mellitus was denied, the published record says the denial is worth fighting.