Cont Glucose Monitor for Endocrine/Metabolic: 88.3% of denials overturned
In 60 California IMR decisions from 2008 to 2020, reviewers overturned 53 (88.3%). 45 were medical-necessity disputes, 15 experimental/investigational.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 21 | 95.2% | 88.3% |
| Urgent or emergencyThe findings mention urgency. | 3 | 100.0% | 88.3% |
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 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 …”
“Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an external ambulatory infusion pump for insulin with accessories (E0784, A4230, and A4232). Findings: The physician reviewer found that Continuous glucose monitoring systems enable patients to effectively control and adjust their insulin therapy. Continuous glucose monitoring systems have been found effective in lowering hemoglobin A1c (HbA1c) significantly …”
And one the reviewer upheld
“The patient has requested authorization and coverage for Freestyle Libre Sensors for glucose monitoring. The Freestyle Libre is a continuous glucose monitor (CGM) that is useful for diabetic patients for improving safety with frequent hypoglycemic events or with hypoglycemic unawareness. The device allows blood sugar readings to be obtained on an ongoing basis. With this information, the patient is allowed …”
- 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 for Endocrine/Metabolic overturned?
In 60 California IMR decisions from 2008 to 2020, reviewers overturned 53 (88.3%). 45 were medical-necessity disputes, 15 experimental/investigational.
What should an appeal document, based on these findings?
Whatever the plan's criteria ask for, shown in the record: the treatments already tried and their results, contraindications to the plan's preferred option, the guideline or evidence that supports the request, and the treating clinician's reasoning written to the criteria. The tag table shows which of these the reviewers mentioned most in overturned cases.
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 they weigh the same things.
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.