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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dexcom continuous glucose monitoring (CGM). Per the American Association of Clinical Endocrinologists (AACE), providers individualize the choice of diabetes therapies for each patient based on the specific attributes of the patient and the medications. Medication attributes that affect this choice include antihyperglycemic efficacy; mechanism of action; risk of inducing hypoglycemia; risk of weight gain; other adverse effects; tolerability; ease of use; likely adherence; and safety or risk reduction in heart, kidney, or liver disease. Minimizing the risk of both severe and non-severe hypoglycemia is a priority. Self-monitoring of blood glucose is required in all patients taking insulin. Increased frequency of monitoring is recommended for patients taking mealtime insulin. Use of a CGM provides real-time glucose data and alarms for hyper- and hypo-glycemic excursions and events. A study found that a high percentage of patients who received multiple daily insulin injections for type 2 diabetes used CGM on a daily or near-daily basis for 24 weeks had improved glycemic control. A review of the record indicates that this patient has a history of type 2 diabetes. She has failed oral medical therapy and she is currently on multiple doses of insulin based on carbohydrate counting. The records document dawn phenomenon and premeal blood glucose levels exceeding 300 mg/dL. The patient has severe fear of hypoglycemia. She has experienced glucose levels as low as 15 mg/dL so she tends to underdose her insulin and keeps her glucose levels high, with a hemoglobin A1C of 11%. Her provider recommended the Dexcom CGM to help her to manage her diabetes as this device has alarms that will alert the patient when the glucose levels are dropping, allowing her to act prior to becoming hypoglycemic. This patient has diabetes mellitus type 2 but she is insulin deficient, and is insulin dependent at this time. This makes her management similar to that required by a type 1 diabetes patient. This places the patient at risk for glucose fluctuation and hypoglycemia, which she may not be aware of without a CGM. The provider recommended a Dexcom CGM to help prevent hyper- and hypo-glycemic events. The most recent Dexcom G6 CGM includes a new alert that is triggered when an algorithm predicts that an estimated glucose value 55 mg/dL will occur within 20 minutes, allowing users more time to act to avoid hypoglycemia. Therefore, the Dexcom CGM is medically necessary to improve the management and control of this patients diabetes mellitus.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 subspecialty certification in diabetes, endocrinology 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.