Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 36-year-old female with type 1 diabetes mellitus and multiple microvascular complications including hypoglycemia unawareness, diabetic retinopathy, etc. Her most recent A1C is in the mid 5% (normal) range. At present these problems are ongoing. The patient is requesting authorization for a continuous monitoring product called a Glucowatch. The Health Plan has denied coverage for the requested equipment indicating it is considered investigational at this time.Though the Glucowatch has several potential benefits, the device has never been shown in practice to substantially improve diabetes control, prevent or reverse microvascular complications or reverse hypoglycemic unawareness. With diabetes autonomic neuropathy (DAN), sweating patterns are dysregulated and sweating defeats the hypoglycemic alarm system, thus not solving the patients problem. Furthermore, in the case of this patient, there is no evidence the patient has been followed in conjunction with an endocrinologist, the expert in insulin pump therapy and usage. Moreover, there is no indication the patient has been evaluated for gastroparesis, a common occurrence in patients with DAN. If gastroparesis is present, the requested equipment will not in and of itself obviate the patients erratic absorption of food. For these reasons, I have determined that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient has a history of type 1 diabetes mellitus. The patients provider states the patient has a history of hypoglycemia unawareness and nocturnal hypoglycemia. The patients provider also indicates the patient has a history of inadequate blood glucose control, uncontrolled blood glucose levels, and retinopathy. The patients provider has recommended a Glucowatch. The Health Plan indicates it has not been established that the Glucowatch is a more effective device than available standard glucose monitoring devices. Therefore, the Health Plan has denied authorization for the requested equipment.The submitted information does not indicate whether the patient is being followed by an endocrinologist for her apparent multiple endocrinopathies. The patients blood sugar levels, frequency of hypoglycemic episodes, and severity of hypoglycemic episodes are not known. Based upon the information provided, there is insufficient evidence the patient is likely to benefit from the requested equipment. It appears a consultation with an endocrinologist is in order. Based upon the information set forth above, I have determined that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 36-year-old female with type 1 diabetes mellitus with an apparent history of hypoglycemia unawareness and nocturnal hypoglycemia. The patients provider also indicates the patient has a history of inadequate blood glucose control, uncontrolled blood glucose levels, and retinopathy. A Glucowatch monitoring device has been requested for the patient. The Health Plan indicates the Glucowatch has not been proven to be more effective than standard monitoring devices. Based upon the information provided, there is no clinical data suggesting the Glucowatch will benefit this patient. There is no evidence the patient has undergone an endocrinology workup in order to determine the most appropriate treatment for her condition. At this time there is no evidence the Glucowatch is likely to be superior to standard monitoring devices for this patient. Accordingly, I have determined that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.