Diagnosis: Type I Diabetes Mellitus.
Treatment: E0784 External Ambulatory Infusion Pump Insulin (Tandem t:slim X2).
The insurer denied the E0784 External Ambulatory Infusion Pump Insulin (Tandem t:slim X2).
The denial is overturned.

This patient is an adult male with type I diabetes. Request for t:slim X2 insulin pump is under review. The prior request was denied because the patient has a pump in warranty. The provider is appealing this determination as the patient has tried and failed the Medtronic 770G insulin pump he has been using. His glycated hemoglobin (A1C) was 7.8%. He changed continuous glucose monitors to Dexcom because the Medtronic sensors were inaccurate, and the adhesive fell off his skin. The patient's average blood glucose on pump download was 226 milligrams per deciliter (mg/dL).

The proposed t:slim X2 insulin pump is medically necessary.

This request is for a t:slim X2 insulin pump for the management of type I diabetes. This patient has tried and failed the Medtronic 770G due to ongoing hyperglycemia with a glycated hemoglobin (A1C) of 7.8% and average blood glucose of 226 milligrams per deciliter (mg/dL). The use of the t:slim X2 pump is supported by the peer reviewed literature for the management of type I diabetes to reduce hyperglycemia and reduce hypoglycemia. In a randomized control trial of 168 patients with type I diabetes, the mean (±standard deviation) percentage of time that the glucose level was within the target range (70 to 180 milligrams per deciliter [mg/dL]) improved in the group using the t:slim X2 pump with Control IQ from 61±17% (percent) at baseline to 71±12% during the six months and remained unchanged at 59±14% in the control group (mean adjusted difference, 11 percentage points; 95% confidence interval [CI], nine to 14; P<0.001). Use of the t:slim X2 pump with Control IQ also reduced hypoglycemia with a mean difference in the percentage of time that the glucose level was less than 70 milligrams per deciliter (mg/dL) was 0.88 percentage points (95% CI, 1.19 to 0.57; P<0.001). Without the t:slim X2 pump, this patient will be at increased risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, the proposed Tandem t:slim X2 insulin pump is medically necessary.