Glucose Monitor denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that An enrollee has requested authorization and coverage for Dexcom G6 continuous glucose monitor system (including sensors, transmitters, and receiver). In this case, notes report diagnoses of hypoglycemia and Raynaud’s disease. The patient does not have diabetes. In an application for independent medical review, the patient reports having to test glucose levels using finger sticks several times daily. The patient reports that the use of finger sticks is challenging as Raynaud’s disease causes the patient's fingers to lack daily blood flow. The patient reports a history of dangerous hypoglycemia levels leading to a loss of consciousness. Hypoglycemia may occur in patients without diabetes due to multiple causes and is dangerous condition.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for FreeStyle Libre continuous glucose monitoring system (CGMS) and sensors, and brand name Crestor 20 mg tablets. The records provided for review document that this patient has poorly controlled diabetes, with a hemoglobin A1C of 11.6%. The patient has refused treatment with oral agents, citing allergies to oral medications metformin and sulfa antibiotics. The patient reports that she is unable to do finger sticks and she has requested FreeStyle Libre CGMS for monitoring her glucose levels. The FreeStyle Libre System is a wireless method for self-monitoring of glycemic control, which uses a sensor for monitoring interstitial fluid glucose. Per the U.S.

Where the denial was upheld

Findings: The physician reviewer found that The patient has requested authorization and coverage for an insulin pump. Insulin pumps can be considered for the treatment of patients with type 2 diabetes who are on multiple daily insulin doses or have other types of diabetes resulting in insulin deficiency. Insulin pumps deliver rapid-acting insulin to patients throughout the day to help manage their blood glucose levels. Managing diabetes with an insulin pump may provide better glycemic and metabolic control to patients by reducing hemoglobin A1c, glycemic variation, and hypoglycemia. According to the American Diabetes Association (ADA), the use of an insulin pump requires a commitment by the patient to use the pump safely. The ADA asserts that an insulin pump does not eliminate the need to check blood glucose or provide insulin before meals.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for one additional Dexcom G6 sensor, totaling four sensors per month. Blood glucose monitoring is essential to diabetes management. In this case, the patient is using the OmniPod 5 insulin pump, which has the capability of communicating with the patient’s DexCom G6 continuous glucose monitor (CGM). The patient has been using this closed-loop pump for several years. The patient is requesting an additional DexCom sensor every month, for a total of four per month, citing concern about potential skin irritation that could become infected by changing sensors every 10 days rather than every seven days.

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