Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes
Treatment: Dexcom G6 CGM (Continuous Glucose Monitoring) system
The insurer denied coverage for Dexcom G6 CGM system.
The denial is overturned.

The patient is an adult, with diabetes mellitus (DM) secondary to pancreatectomy. The patient has erratic blood sugars, and the treating provider is requesting a plan approval for the Dexcom G6 continuous glucose monitor (CGM) system to help monitor the blood sugar levels.

"Further technological advances in CGM revolutionized diabetes care. It is now accepted that CGM increases quality of life by allowing informed diabetes management decisions as a result of more optimized glucose control. This leads to a better health and a reduction in diabetic complications. Although CGM requires a higher initial investment, the trust is that long-term health benefits of CGM are cost-effective when compared to daily use of test strips" (Didyuk, O., et al. 2021).

"While self-monitoring of blood glucose (SMBG) is the current standard used by people with diabetes to manage glucose levels, recent improvements in accuracy of continuous glucose monitoring (CGM) technology are making it very likely that diabetes-related treatment decisions will soon be made based on CGM values alone. No adjunctive use of CGM will lead to a paradigm shift in how patients manage their glucose levels and will require substantial changes in how care providers educate their patients, monitor their progress, and provide feedback to help them manage their diabetes. The approval to use CGM non-adjunctively is also a critical step in the pathway toward Food and Drug Administration (FDA) approval of an artificial pancreas system, which is further expected to transform diabetes care for people with type 1 diabetes. In this article, we discuss how nonadjunctive CGM is expected to soon replace routine SMBG and how this new usage scenario is expected to transform health outcomes and patient care" (Castle, J. R., &amp; Jacobs, P. G., 2016).

"Diabetes can lead to life-threatening consequences if it is not managed appropriately. Over time, it can cause various macrovascular and microvascular complications (such as cardiovascular disease, renal disease, retinopathy, and/or neuropathy), resulting in an overall reduction in blood flow. People with diabetes are twice as likely to develop heart disease or to experience a stroke, and the condition is also the leading cause of renal failure, limb amputations, and adult blindness (retinopathy). In addition, there is a 30-40% increase in prevalence in diabetics who smoke, leading to an even greater risk of heart- and kidney-disease complications. These complications affect patients' overall health and quality of life and increase the risk of mortality by 50%" (Funtanilla, V. D., et al. 2019).

"CGM can provide both retrospective as well as real-time information to detect: 1) hypoglycemic and hyperglycemic excursions; 2) predict impending hypoglycemia; and 3) wide fluctuations in glucose levels, also known as glycemic variability. 24-hour telephone support is available for all FDA approved CGM devices. Use of CGM can help both the patient and their medical provider make fine tune adjustments to medication therapy and provide insight to the patient on behavioral changes to achieve glycemic control. Additionally, current efforts to link CGM measurement with automatically controlled insulin delivery, has progressed incrementally toward a fully functional artificial pancreas. Systems can be divided according to their intended use as professional CGM (which is a clinic-owned device and provides either retrospective or real-time glucose data) and personal CGM" (Reddy, N. et al. 2020).

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Dexcom G6 CGM system is substantiated.