Diagnosis: Type II diabetes mellitus
Treatment:Continuous glucose monitoring system
The insurer denied the Continuous glucose monitoring system.
The denial is upheld.
The proposed CGM system is not medically necessary.

This is a female diagnosed with type II diabetes mellitus (T2DM). This request is for continuous glucose monitor (CGM) Libre Freestyle (K0553). As per the denial letter; the patient uses insulin; her A1C was 6.1 %. As per the provider's note; the patient suffers from highly fluctuating blood glucose (BG) levels with hyperglycemia that needs regular monitoring.

Note - there are no log sheets provided for review.

The requested device is a flash glucose monitoring system [1-4] that is FDA approved for persons age 18 and older with diabetes. It has been shown to be effective in patients with type II diabetes who are on intensive insulin therapy. It was associated with sustained reduction in hypoglycemia and safely and effectively replaces blood glucose monitoring [5, 6].

The patient has no documentation of being on an intensive insulin regimen. The patient does not have documentation of self-checking of blood glucoses four or more times a day. Therefore, the request is not medically necessary.