Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for external continuous glucose monitoring system (sensor, transmitter, and monitor) for treatment of the enrollee who has been diagnosed with diabetes type 2. Findings:  The physician reviewer found that The requested equipment is medically necessary for treatment of this patients medical condition. The Health Plan has approved the insulin pump but not the CGM system prescribed to use with the pump. This patient has diabetes mellitus type 2 that is managed with intensive insulin therapy. The continuous glucose monitor (CGM), in conjunction with the insulin pump, has been prescribed to decrease/prevent hypoglycemic reactions in this patient with labile diabetes and hypoglycemia unawareness. Her comorbidities place her at risk for severe hypoglycemic reactions with unawareness.  The patient is not aware when these reactions are happening, which places her at risk for disorientation and loss of consciousness. The patient provides documentation of these episodes, which caused a car accident and attention in the emergency department. The provider describes her condition as labile diabetes mellitus and has appropriately prescribed the insulin pump with continuous glucose monitor. According to the American Diabetes Associations 2017 Standards of Medical Care in Diabetes, Treatment decisions should be timely, rely on evidence-based guidelines, and be made collaboratively with patients based on individual preferences, prognoses, and comorbidities. Providers should consider the burden of treatment and self-efficacy of patients when recommending treatments. Treatment plans should align with the Chronic Care Model, emphasizing productive interactions between a prepared proactive practice team and an informed activated patient. When feasible, care systems should support team-based care, community involvement, patient registries, and decision support tools to meet patient needs. In this patients case, CGM is medically necessary to minimize and prevent the risk of severe hypoglycemic reactions. Studies have shown that the frequency of CGM detected low glucose events was several fold higher than that of self-reported hypoglycemia (symptoms with blood glucose less than 56mg/dl]). The medical literature has also confirmed the benefits of CGM in the reduction of hypoglycemia on patients with diabetes type 1 and on patients with diabetes type 2 with specific problems such as the dumping syndrome, as in this patients case. For all these reasons, external CGM system (sensor, transmitter, and monitor) is medically necessary for monitoring this patients medical condition.  Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.