Continuous Glucose Monitor denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with type 1 diabetes, hyperlipidemia, hypoglycemia, and left non-proliferative retinopathy. On 8/23/18, the patient’s hemoglobin A1c level was 7.4. In a report dated 1/24/19, the patient reported hypoglycemic episodes. His home blood glucose logs show frequent hypoglycemic events. The patient had been treated with Lantus and Humalog. On 2/5/19, the patient’s hemoglobin A1c level was 7.1. The patient’s provider adjusted his insulin doses to avoid hypoglycemia. The patient requested coverage for an insulin pump and continuous glucose monitor. The Health Plan denied the request and reported the requested equipment was not medically necessary for the evaluation and treatment of this patient.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an insulin pump and continuous glucose monitor (CGM). Current studies have shown that tight glucose control reduces the risk, delays the onset, and slows the progression of complications. According to the American Diabetes Association (ADA), most adults with type 1 diabetes should be treated with intensive insulin therapy with either multiple daily injections or an insulin pump. Pump therapy can be successfully started at the time of diagnosis and has been shown to be superior in lowering hemoglobin A1C over multiple doses of insulin. Regarding continuous glucose monitor (CGM) devices, the ADA recommends sensor-augmented pump therapy may be considered for adults to improve glycemic control without an increase in hypoglycemia or severe hypoglycemia.

Where the denial was upheld

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.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a continuous glucose monitor (CGM). The indication for a CGM depends on several factors, including the type of diabetes, the patient's current glycemic control, and the presence of hypoglycemia unawareness or frequent hypoglycemic episodes. According to the American Diabetes Association (ADA), real-time CGM (rtCGM) is recommended for teenagers and adults with type 1 diabetes who are not meeting glycemic targets or have hypoglycemia unawareness and/or episodes of hypoglycemia. Additionally, the ADA recommends the use of CGM in adults with type 2 diabetes who are using insulin and not meeting glycemic targets. For patients with type 1 diabetes, the use of rtCGM has been shown to lower HbA1c concentrations and reduce hypoglycemia.

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