Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with type 1 diabetes, hyperlipidemia, hypoglycemia, and left non-proliferative retinopathy. On 8/23/18, the patients hemoglobin A1c level was 7.4. In a report dated 1/24/19, the patient reported hypoglycemic episodes. His home blood glucose logs show frequent hypoglycemic events. The patient had been treated with Lantus and Humalog.  On 2/5/19, the patients hemoglobin A1c level was 7.1. The patients provider adjusted his insulin doses to avoid hypoglycemia. The patient requested coverage for an insulin pump and continuous glucose monitor. The Health Plan denied the request and reported the requested equipment was not medically necessary for the evaluation and treatment of this patient. At issue in this case is whether the requested insulin pump and continuous glucose monitor are medically necessary for the evaluation and treatment of the patients medical condition. The 2019 guidelines from the American Diabetes Association (ADA) note sensor-augmented pump therapy with automatic low-glucose suspend can be considered for adults with type 1 diabetes at high risk of hypoglycemia to prevent episodes of hypoglycemia and reduce their severity. To provide physiologic insulin delivery, insulin doses need to be adjusted based on glucose values, which is feasible with automated insulin delivery systems consisting of three components: an insulin pump, a continuous glucose sensor, and an algorithm that determines insulin delivery. Insulin delivery cannot only be suspended but can also be increased or decreased based on sensor glucose values. A closed loop insulin delivery system deceases hypoglycemia and increases time in target blood glucose range (Sherr, et al.). This finding has been confirmed in other studies that showed improvement of glycemic control and HbA1c levels (Battelino, et al.). The patient has diabetes-related complications and frequent hypoglycemic events. He is testing his glucose levels before meals and administering insulin as instructed, per the carbohydrate counting method. He continues to have hypoglycemic events. He would benefit from a closed loop system or a hybrid system of an insulin pump with a continuous glucose monitor that can stop insulin delivery when a blood glucose low is predicted to avoid hypoglycemia and increase insulin delivery based on glucose levels. The patient reported that hypoglycemic events have caused loss of consciousness and head injuries in the past. Medical evidence supports the request in this clinical setting. Therefore, the requested insulin pump and continuous glucose monitor are medically necessary for evaluation and treatment of this patient.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 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.