Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 Diabetes Mellitus
 
Treatment: Continuous Glucose Monitoring System K0553- Supply allowance for Therapeutic Continuous Glucose Monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service

The insurer denied the Continuous Glucose Monitoring System K0553- Supply allowance for Therapeutic Continuous Glucose Monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service. The denial was reversed.    

This is a male patient who has a diagnosis of Type 2 Diabetes Mellitus. The patient has a history of congenital rubella syndrome, CVA, hearing impaired and extremely poor visual acuity. It is reported that due to the patient poor visual acuity he is unable to use his glucometer to monitor his blood glucose or use a talking meter. It is further reported that he is unable to use a lancet. In late 2018 the patient began using the Freestyle Libre meter. The use of this instrument allowed the patient to not only see the reader but more importantly allowed him to accurately trend his glucose results facilitating his ability to treat the glucose result accordingly; hypo/hyperglycemia. 

According to current literature, many new types of technology are increasingly being developed and applied to fight diabetes and its complications. These new technologies to include continuous glucose monitoring will improve the lives of people with diabetes by measuring glucose and other biomarkers. Within the submitted documentation, it was noted that this patient had been diagnosed with type 2 diabetes along with several other comorbidities, including proliferative diabetic retinopathy, retinal vein thrombus, and congenital rubella syndrome. The patient had a recent stroke in early 2018. The documentation indicated that the patient required testing of his blood glucose four times per day and was treated with injections of insulin four times per day. The patient is unable to utilize the glucometer to test his blood glucose due to poor vision. A talking meter is not appropriate because the patient cannot adequately obtain blood from the lancet due to the poor vision. 

Although this requested Freestyle Libre glucose monitoring system is not typically recommended for this population of patient, this medical situation incudes exceptional circumstances that should be reasonably applied to the consideration of the request. Without the ability to monitor blood glucose levels on a regular basis throughout the day, this patient is at a significantly higher risk for complications. The use of a Freestyle Libre glucose monitoring system will provide a safe and appropriate option to allow this patient to regularly monitor blood glucose levels so that appropriate adjustments can be made to his medical regimen throughout the day. This will also reduce his need for traditional finger sticking which is documented to be very difficult for the patient due to his very poor vision.

Based on the above, the medical necessity for the Continuous Glucose Monitoring System K0553-Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply= 1 unit of service is substantiated. The insurer's denial is reversed.