Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a therapeutic continuous glucose monitor
(CGM), and all supplies and accessories for the enrollee.
You asked the Plan to provide coverage for a therapeutic continuous glucose monitor (CGM), and all supplies
and accessories. You say that this equipment is medically necessary for the enrollee. The Plan denied your
request. The Plan says Medicare criteria are not met. Maximus overturned the Plans denial. The Plan requested
a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a therapeutic
continuous glucose monitor (CGM), and all supplies and accessories. The Maximus Physician Reviewer
determined that the enrollee has diabetes mellitus and has suboptimal control on bid insulin shots. The
enhanced ability to check with the libre would help the enrollee adjust, diet, and perhaps doses of insulin;
hence, using this Food and Drug Administration (FDA) approved device in this clinical setting.
The Plan has requested a re-opening, citing an error on the face of the evidence. The plan has stated that it
disagrees with our consultant's determination. The plan notes that the documentation submitted does not
indicate the provider ordered the denied items or discussed the need for the item; therefore, the billed supply
code cannot be verified. Additionally, the proof of delivery submitted by the supplier shows a delivery date of
November 20, 2020, but the claim being appealed is for date of service November 30, 2020.
The medical records show the enrollee is a now 68-year-old man with diabetes. A continuous glucose
monitoring system and monitoring supply patches were ordered on November 4, 2020, with listed diagnoses of
Type 1 diabetes without complications, and Monitoring supply patch. The clinical note dated December 11,
2020 documents a plan for the enrollee's diabetes of "Continue on meds as above." The clinical notes dated
between September 23, 2020 and December 21, 2020 do not document need for this equipment. The enrollee's
HgbA1c on 12/16/2020 was elevated (9.5%). The Plan is correct in this case. The documentation does not
contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type
and quantity of items ordered and for the frequency of use or replacement (if applicable). The clinical
information does not contain sufficient pertinent information including, but not limited to, clinical course,
prognosis, nature and extent of functional limitations, other therapeutic interventions and results, experience
with related items. Medicare coverage criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a therapeutic continuous glucose monitor (CGM), and all supplies and
accessories have not been met. Therefore, we decided that the Plan does not have to provide coverage for a
therapeutic continuous glucose monitor (CGM), and all supplies and accessories for the enrollee.