Cont Glucose Monitor denials in California external review

What the reviewers wrote

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

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.

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 Cont Glucose Monitor, then check the rights and deadlines that apply to your plan.