Diagnosis: Type 2 Diabetes.
Treatment: Diabetic Medical Equipment (DME)/Durable medical equipment (Continuous glucose monitoring device).
The health plan denied the requested Durable medical equipment (Continuous glucose monitoring device) as not medically necessary.
The health plan's determination is overturned.

This is a female with type 2 diabetes. She is on insulin injections three times daily. She has difficulty checking her glucose with traditional lancets. Her hemoglobin A1C (HbA1c) was 10.3%.
At issue is the medical necessity for the requested durable medical equipment (continuous glucose monitoring device).

I overturn, in whole, the health plan's determination of medical necessity.

The requested continuous glucose monitoring device is medically necessary. This request is for a continuous glucose monitor for a patient with uncontrolled type 2 diabetes. In a randomized controlled trial, Dexcom continuous glucose monitoring was shown to lower hemoglobin A1C in patients with uncontrolled type 2 diabetes on multiple daily insulin injections (adjusted difference in mean change of hemoglobin A1C with use of continuous glucose monitoring, -0.3%. In a second study of 101 patients with type 2 diabetes on two or more injections per day, use of the continuous glucose monitoring system significantly improved hemoglobin A1C levels. The changes in HbA1c were -0.82% vs. -0.33% in the intervention group using the continuous glucose monitoring system and control group, respectively, and 68.6% of the patients in the intervention group using the continuous glucose monitoring system had their HbA1c reduced by 0.5% compared with 30.2% in the control group, and 39.2% had their HbA1c reduced by 1.0% vs. 18.6% in the control group without an increased frequency of hypoglycemia. [1] This patient has uncontrolled type 2 diabetes, and she takes insulin injections three times daily. Her hemoglobin A1C was very elevated at 10.3%. In this clinical situation, as outlined above, the use of continuous glucose monitoring (CGM) has been shown to reduce hyperglycemia. Without CGM, this patient will remain at significant risk of ongoing hyperglycemia which would increase her risk for retinopathy, neuropathy, and nephropathy.
Therefore, the requested continuous glucose monitoring device is medically necessary for this patient.