Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type 2 Diabetes. 
Treatment: Dexcom G6 Sensor. 

The insurer denied coverage for Dexcom G6 Sensor. 

The denial is overturned. 
 
This case involves an adult patient diagnosed with type 2 diabetes mellitus and autism who was utilizing a Dexcom continuous glucose monitor (CGM) as part of the treatment plan. 

The patient's progress notes noted the patient was diagnosed with autism, diabetes mellitus, hyperlipidemia, and hypothyroidism. The patient was taking multiple medications and utilized the Dexcom G6 sensor. The physician stated that the patient has limited abilities to communicate verbally due to autism and spends a considerable time of the day at a daycare facility while the parents are working. The patient has shown significant improvement in the diabetes mellitus to control the use of insulin, non-insulin therapies, with continuous glucose monitor (CGM) use. The patient has experienced hypoglycemia on occasions and due to the neurologic condition, cannot clearly express this to others. With the current regimen, if the patient's blood glucose levels decreased to low values, the patient's parents are alerted, and can then reach out to the daycare facility and have this properly treated before significant complications develop. On another occasion, the parents were alerted to low glucose levels while the patient was sleeping, which allowed them to wake the patient up and treat effectively. 

The formulary alternatives require regular AccuCheks, which could overstimulate the patient. Additionally, given that the patient is nonverbal, if there were to be any episodes of hypoglycemia, the patient would be unable to alert those near to treat the hypoglycemia effectively by performing an Accu-Chek and administering either medication or providing with a means of improving the glycemic level. 

The formulary alternative is to discontinue use of the CGM device and perform AccuCheks, which would not be appropriate for this patient who is autistic and nonverbal and could place the patient at an increased risk for hypoglycemic episodes. 

Literature notes that the concept of implantable glucose sensors have been probated for more than 40 years and it is now accepted that continuous glucose monitoring (CGM) increases quality of life by allowing informed diabetes management decisions as a result of more optimized glucose control. 

The information provided for review noted that the patient had a diagnosis of diabetes mellitus type 2. The patient had used a CGM as part of the treatment plan with benefit. In taking the patient's comorbidity of nonverbal autism into consideration, the use of the CGM device is necessary given that the patient cannot clearly express self to others when the patient is having a hypoglycemic episode. Additionally, patients with autism often times do not tolerate stimulation of any sort from other individuals, which may be elicited with routine AccuCheks. The patient has a complicated medical history and for quality-of-life purposes and to maintain stability in the condition, the patient would be considered an outlier to the formulary alternative regarding AccuChek products with requirement of 3 in a class with 3 or more alternatives, to in class with 2 alternatives, or 1 and a class with only 1 alternative. Given the complexity of the patient's condition, it would be reasonable to continue using the Dexcom G6 sensor. The prior determination is reversed as the Dexcom G6 sensor is the best alternative for this patient. 

The formulary alternatives are expected to cause adverse effects. 

The formulary alternatives were not tried, and the patient did have a contraindication. 

The formulary alternative is expected to be ineffective. 

The not formulary alternative is expected to be more effective than the formulary alternatives. 

The carrier's denial of a request for a Formulary Exception for Dexcom G6 Sensor to monitor blood glucose is overturned.