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Cont Glucose Monitor denials: what the review data shows
Independent reviewers have decided 62 published cases where an insurer denied Cont Glucose Monitor — and they overturned the insurer 88.7% of the time. A denial for Cont Glucose Monitor is a starting position, not a final answer.
Published decisions
62
2001–2026
Overturned
88.7%
55 denials reversed
Conditions behind cont glucose monitor denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Diabetes | 57 | 87.7% |
| Hypoglycemia | 3 | 100% |
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 47 | 89.4% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 15 | 86.7% |
Typical time to a decision
14 days
Most land between 7 and 21 days
Handled as urgent
27.4%
Expedited when a delay would cause harm
Recent direction
Rising
81.8% → 92.6% overturned, last three years
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Dexcom continuous glucose monitoring system. The Health Plan has denied this request indicating that the requested device is not medically necessary for management of the enrollee’s medical condition. Findings: The review of the medical literature supports the use of CGM system in diabetes mellitus type 1 and 2. Appropriate use of real time CGM improved glycometabolic control in type 1 patients. The effects of CGM were more evident in patients under multiple daily insulin treatment, compared with insulin pump therapy. Glucose variability, in addition to glycemic control, was improved in compliant diabetic patients (Tumminia, et al).
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for external continuous glucose monitoring system (sensor, transmitter, and monitor) for treatment of the enrollee who has been diagnosed with diabetes type 2. Findings: The physician reviewer found that The requested equipment is medically necessary for treatment of this patient’s medical condition. The Health Plan has approved the insulin pump but not the CGM system prescribed to use with the pump. This patient has diabetes mellitus type 2 that is managed with intensive insulin therapy. The continuous glucose monitor (CGM), in conjunction with the insulin pump, has been prescribed to decrease/prevent hypoglycemic reactions in this patient with labile diabetes and hypoglycemia unawareness. Her comorbidities place her at risk for severe hypoglycemic reactions with unawareness.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: A 46-year-old male enrollee has requested authorization and coverage for Medtronic 670G insulin pump for treatment of the enrollee’s type I diabetes mellitus. Findings: The physician reviewer found that Multiple studies have referenced meta analyses on insulin pumps which have been able to demonstrate improved mean blood glucose concentration, glucose variability, HbA1c (glycated hemoglobin) and to reduce insulin requirements by 14% over multiple daily injections of insulin in patients capable and motivated to use the insulin pump. It remains the best available option for type 1 diabetes. Continuous glucose monitoring systems (CGMS) including real time systems have been approved by the U.S. Food and Drug Administration. This patient may see a benefit in personal CGMS device. However, the Medtronic 670G insulin pump is a hybrid closed loop pump.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a continuous glucose monitor (CGM). CGM detects glucose variations, time in glycemic target, and time in hypoglycemia. These metrics have been shown to enhance a patient’s self-management of diabetes. In a study by Ida and colleagues aimed to investigate the effects of CGM devices in patients with type 2 diabetes mellitus, the authors found that the CGM group exhibited significantly lower HbA1c levels and spent less time with hypoglycemia. This patient’s records indicate that he has a diagnosis of diabetes of recent onset. However, there is a lack of documentation of a thorough evaluation and discussion on the goals of therapy with his primary care provider or nutritionist.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
How to use this in your appeal
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Cont Glucose Monitorwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.