Insulin Pump 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 parent of a minor enrollee has requested authorization and coverage for an insulin pump. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollee’s type I diabetes. Findings: The physician reviewer found that there is support in the documentation as well as in the medical records for the requested device in this clinical setting. This patient has a history of widely fluctuating blood glucose levels before meals, despite multiple dose adjustments and frequent blood glucose monitoring while receiving a multiple dose insulin injection regimen, which they have implemented since their initial diagnosis more than six months ago.

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.

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 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 Insulin Pump, then check the rights and deadlines that apply to your plan.