Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 Diabetes

Treatment continuous glucose monitoring device

The insurer denied coverage for continuous glucose monitoring device

The denial is overturned

The patient has a history of type 2 diabetes, neuropathy, retinopathy, nephropathy, hypertension, coronary artery disease (CAD), gastroesophageal reflux disease (GERD) hyperlipidemia, and obesity.

The request is for Dexcom continuous glucose monitor (CGM). The request was continuously denied because it was only covered for type 1 diabetes. 

Per office visit, the patient is seen for a follow up visit for diabetes. The patient is currently taking Semglee 35 units a day and Admelog 15 units before meals. Diabetes is poorly controlled with an A1c (glycated hemoglobin) of 8.4% (percent). The patient cannot use a glucometer because of severe neuropathy. Per treating provider appeal the patient has painful neuropathy and cannot check fingerstick. His A1c has improved from 10.2 to 8.4% after use of Dexcom.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.      

The continuous glucose monitoring device considered medically necessary for this patient. 

This patient is on multiple daily injections. The treating provider stated there is an extenuating circumstance that he cannot use fingerstick frequently due to painful neuropathy and has had objective improvement on CGM. Therefore, the Dexcom CGM is medically necessary.

The current diabetes guidelines in the United States (US) are mixed regarding CGM in type 2 diabetes patients.  The AACE (American Association of Clinical Endocrinology) position of CGM and insulin pumps do not make mention of CGM recommendations in type 2 diabetes patients. The Endocrine society position paper on CGM and pumps likewise do not make strong recommendations for CGM use in type 2 diabetes. However, the ADA (American Diabetes Association) standards of care endorsed real-time and intermittently scanned continuous glucose monitors use in adult patients on multiple daily insulin therapy (including type 2 patients) to reduce A1C and/or reduce hypoglycemia in adults who are not meeting glycemic targets.
The ADA recommendations reference the randomized trial Diamond (Beck et al.) published in 2017 showed a 0.3% lower A1c in type 2 diabetes patients using multiple daily injections on CGM versus not on CGM, without differences in rates of hypoglycemia. Two other trials were cited in this decision (Yoo et al. , and Ehrhardt et al.) using oral agents with or without insulin showed significant reductions in A1C levels. These trials, although randomized, had smaller participant numbers and a more heterogenous type 2 diabetes patient population. Separately Gandhi et al. in a metanalysis of CGM use of randomized trials in type 1 and type 2 diabetes pediatric and adult patients on intensive insulin regimen showed a 0.7% comparative lower A1c in the CGM group.  The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for a continuous glucose monitoring device is overturned. Medical Necessity is substantiated.