Diagnosis: Endocrine/Metabolic/Nutritional-Diabetes
Treatment: Diabetic Equipment, Supplies and Self-Management Education-Insulin Pump
The health plan denied the insulin pump as not medically necessary.
The reviewer has overturned in whole the health plan's determination.

The patient has a history of type 1 diabetes and has been on insulin pump therapy. She has a history of diabetic ketoacidosis and diabetic neuropathy.

The requested Insulin pump is medically necessary for this patient. The patient has a past medical history significant for uncontrolled type 1 diabetes mellitus complicated by peripheral neuropathy and frequent diabetic ketoacidosis (DKA). When comparing insulin pump use versus multiple daily injections, insulin pumps have shown to lower average glucose concentrations, decrease glucose variability, reduce HbA1c and incidence of hypoglycemia. (1,2) As per the American Diabetes Association guidelines, insulin pumps are considered necessary especially if patients have a history of frequent hypoglycemia and have extreme insulin sensitivity. (3) Now there are insulin pumps that have automated (hybrid) closed-loop systems that allows the pump to infuse basal insulin automatically that is determined by an algorithm based on the results of the glucose readings derived from a continuous glucose monitor. One study has shown the hybrid-closed loop system to decrease HbA1c levels from 7.7% to 7.1% and 7.3% to 6.8% in adolescents and adults, respectively (4). In a meta-analysis of trials comparing the use of this hybrid-closed loop therapy in non-pregnant patients with type 1 diabetes, the proportion of time spent in normal glycemic levels was significant higher with the hybrid-closed loop therapy. (5) Moreover, the incidence of severe hypoglycemia is significantly reduced.
Given this patient's poorly controlled Type 1 Diabetes and her outdated/damaged insulin pump, the tandem pump is medically necessary for this patient given this patient's glucose variability.
There is evidence that the patient's pump is damaged, has cracks, and is illegible to the patient. The patient's pump is also out of warranty and damaged and in need of repair.