Diagnosis: Type 2 Diabetes

Treatment: continuous glucose monitoring device (CGM) and supplies, A4239 x 1 & E2103 x 1

The insurer denied coverage for continuous glucose monitoring device (CGM) and supplies, A4239 x 1 and E2103 x 1

The denial is overturned


The patient is seeking authorization for continuous glucose monitoring device (CGM), and supplies A4239 x 1 and E2103 x 1. The patient was diagnosed with uncontrolled insulin requiring type 2 diabetes mellitus complicated by peripheral neuropathy, microalbuminuria, and retinopathy.

A request was noted for continuous glucose monitoring device with supplies. The patient was diagnosed with type 2 diabetes mellitus with unspecified complications. The patient had wide fluctuations in blood glucose values which ranged from 40 to 400. The patient was receiving 4 insulin injections a day. The patient was testing their blood sugar 6 times a day. There was a dawn phenomenon with morning hyperglycemia. There was fasting hyperglycemic of greater than 150. The patient's hemoglobin A1c was 12.7. The patient completed a comprehensive diabetic education program.

Per the cited references, continuous glucose monitoring (CGM) is indicated for those with intensive insulin regimen (4 or more daily insulin injections, or use of continuous subcutaneous insulin infusion pump) when the patient is educated or scheduled to be educated on use of continuous glucose monitoring.

In this case, the patient had uncontrolled type 2 diabetes mellitus that required glucose monitoring 6 times a day and insulin 4 times a day. While it is noted that the patient had some difficulty with compliance in the past, this does not negate the need for continuous glucose monitoring. The patient has elevated hemoglobin A1c which places the patient at increased risk for numerous complications of diabetes mellitus. Additionally, the documentation details routine laboratory has been completed over several years and that the patient is currently being compliant with routine follow-up. It is standard of care for continuous glucose monitoring in patients with intensive insulin regimens and the monitoring is likely to result in improvement of health status for the patient with better glycemic control. As such, the continuous glucose monitoring device and supplies as medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for a continuous glucose monitoring device (CGM) and supplies, A4239 x 1 and E2103 x 1 is substantiated.