Cont Glucose Monitor denials: 88.7% overturned by independent reviewers
In 62 California IMR decisions from 2008 to 2020, reviewers overturned the plan 55 times (88.7%). Denials reach IMR only when a member appeals all the way; read the caveats below before generalising.
By diagnosis
| Diagnosis category | Decisions | Overturned | Last 5 years |
|---|---|---|---|
| Endocrine/Metabolic | 60 | 88.3% | — |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 22 | 95.5% | 88.7% |
| Urgent or emergencyThe findings mention urgency. | 3 | 100.0% | 88.7% |
Keyword matches on the reviewer’s findings, not causes. A tag that appears mostly in overturned decisions is worth documenting in an appeal; it is not a guarantee.
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with type 2 diabetes, peripheral neuropathy, hyperglycemia, and mixed hyperlipidemia. The patient reported that he does not monitor his blood glucose due to the pain of needle stick and his peripheral neuropathy. Laboratory results revealed the patient’s hemoglobin A1c level was 8.1. The patient has requested authorization and coverage for …”
“Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with type 2 diabetes. The patient was being treated with Invokana, Janumet, and glimepiride. The patient reported his fasting blood glucose levels were between 130 and 150 mg/dL. The provider noted a hemoglobin A1c level was 7.7%. The provider noted the patient needed an increased frequency of blood glucose checks. …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continuous glucose monitoring (CGM) system (external receiver, CGM system; disposable sensor, CGM system; and an external transmitter, CGM). A CGM system is one of several U.S. Food and Drug Administration (FDA)-approved devices that use interstitial glucose monitoring to display glucose concentrations frequently throughout the day. This regular …”
- California only: these are decisions by independent reviewers under California's IMR program (plans regulated by the Department of Managed Health Care). Other states and self-funded employer plans use different reviewers and rules.
- Selection: only denials that a member took all the way to IMR appear. Most denials are never appealed, and the ones that reach an external reviewer are not a random sample.
- Overturned means the reviewer disagreed with the plan; it does not mean the treatment worked or that a similar request will be approved.
- Argument tags are keyword matches on the reviewer's findings. They describe what the findings mention, not why the case was decided.
- Categories are DMHC's own labels (treatment sub-category and diagnosis category); 'Other' is a catch-all and is excluded from rankings.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, Trend (CHHS Open Data). Public California government data; Apellica's aggregates and tags are CC BY 4.0.
Questions
How often were Cont Glucose Monitor denials overturned?
In 62 California IMR decisions from 2008 to 2020, reviewers overturned the plan 55 times (88.7%).
What did the reviewers' findings mention in overturned cases?
The table on this page counts keyword matches in the findings: prior therapies tried, contraindications, guidelines cited, published evidence, whether the records supported the request. They describe what the findings say, not why the case was decided.
Does a California IMR result apply to my plan?
Only California plans regulated by the Department of Managed Health Care go to IMR. Other states and self-funded employer plans use different reviewers, but the reasoning is the same kind: criteria, documentation and alternatives. Use the findings as a guide to what to document.
Related: California appeal rights · California external-review reversal rate · The levers library · CSV
Independent reviewers reverse plans when the record answers the criteria. Upload the denial letter; a senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.