CASE-007

Section 1 of 4

What the payer refused, and why

Patient

Jeromy Upton

Payer

NORTHBECK HEALTH PLAN

Service denied

Continuous glucose monitoring system, receiver and transmitter CPT/HCPCS E2103 · ICD-10 E11.65 · dated 6 July 2026
Continuous glucose monitor sensors, one month supply CPT/HCPCS A4239 · ICD-10 E11.65 · dated 6 July 2026

Payer's stated reason

The clinical information submitted does not establish that the requested continuous glucose monitoring system is medically necessary under the plan's applicable medical policy. Specifically, the submitted documentation does not establish that the member is treated with an intensive insulin regimen as that term is defined in the applicable policy, and does not establish that self-monitoring of blood glucose has been insufficient to guide therapy.

Section 2 of 4

The clinical argument, criterion by criterion

The patient is a 59-year-old male with type 2 diabetes on an intensive four-injection daily insulin regimen. Due to recurrent hypoglycaemia episodes and emerging hypoglycaemia unawareness, his endocrinologist recommended a continuous glucose monitor. His self-monitoring by fingerstick was documented as insufficient to safely manage his insulin titration, and he has completed device-specific training with a diabetes educator.

Each row is a requirement in the payer's own policy, the verdict reached on it, and the chart text that verdict rests on. 6 of 11 are satisfied with evidence. Read the quotations against what you remember of the care. There is no confidence column: nothing you are about to sign changes at ninety-four percent rather than eighty-eight.
Criterion	Verdict	Chart evidence
NBH-ENDO-031-3.1 The member has a documented diagnosis of type 1 diabetes mellitus, or type 2 diabetes mellitus treated with an intensive insulin regimen consisting of three or more injections of insulin per day or continuous subcutaneous insulin infusion.	Satisfied The record documents type 2 diabetes mellitus treated with an intensive insulin regimen of four injections per day (insulin glargine nightly and insulin lispro three times daily).	Fifty-nine year old man with type 2 diabetes mellitus of nine years' duration, currently on a multiple daily injection regimen: insulin glargine 38 units nightly plus insulin lispro three times daily with meals, four injections per day total, alongside metformin 1000 mg twice daily. enc/2026-05-19/endocrinology
NBH-ENDO-031-3.2 The member, or the member's caregiver, has completed a documented training session on the use and interpretation of the requested device, or such training is scheduled prior to dispensing.	Satisfied The member and his spouse completed a comprehensive training session on the use and interpretation of the continuous glucose monitoring system with a Certified Diabetes Care and Education Specialist.	Completed a forty-five minute structured training session with the patient and his spouse on the use, application, calibration and interpretation of the prescribed continuous glucose monitoring system. enc/2026-06-11/diabetes-education
NBH-ENDO-031-3.3 The member has had at least one in-person or telehealth evaluation with the treating clinician within the six months preceding the request, at which diabetes management was addressed.	Satisfied The patient had a telehealth evaluation with his endocrinologist on July 14, 2026, where his diabetes management was thoroughly reviewed.	Diabetes management discussed in full: insulin regimen unchanged, fingerstick frequency unchanged at two to three per day. enc/2026-07-14/endocrinology
NBH-ENDO-031-3.4 At least one of the following is documented within the twelve months preceding the request: - A hemoglobin A1c result of 7.0 percent or greater; or - One or more episodes of level 2 hypoglycaemia, defined as a blood glucose measurement below 54 mg/dL; or - One or more episodes of documented hypoglycaemia unawareness; or - One or more emergency department visits or hospital admissions for hyperglycaemia or diabetic ketoacidosis.	Insufficient documentation Downgraded automatically: the criterion was marked satisfied but no surviving chart evidence supports it. The member had a hemoglobin A1c of 8.6% on May 19, 2026, which is greater than the 7.0% threshold.	No chart evidence cited
NBH-ENDO-031-3.5 The prescribing clinician has documented that self-monitoring of blood glucose by fingerstick has been insufficient to guide therapy adjustment, or that the member is unable to perform fingerstick testing at the frequency the treatment plan requires.	Satisfied The clinician explicitly documented that fingerstick monitoring is insufficient to guide therapy titration because overnight and mid-shift glucose excursions are going undetected.	Because his overnight and mid-shift excursions are going undetected, fingerstick monitoring at the frequency he is able to sustain is insufficient to guide safe titration of his mealtime insulin. enc/2026-05-19/endocrinology
NBH-ENDO-031-4.1 A clinical note from the treating clinician dated within six months of the request that states the diabetes type, the current insulin regimen, and the clinical rationale for continuous monitoring.	Satisfied The endocrinology clinical note from Dr. M. Castellanos on 2026-05-19 documents the patient's type 2 diabetes, his current multiple daily injection insulin regimen, and the clinical rationale that fingerstick monitoring is insufficient to guide safe insulin titration due to undetected excursions.	Fifty-nine year old man with type 2 diabetes mellitus of nine years' duration, currently on a multiple daily injection regimen: insulin glargine 38 units nightly plus insulin lispro three times daily with meals, four injections per day total, alongside metformin 1000 mg twice daily. enc/2026-05-19/endocrinology Because his overnight and mid-shift excursions are going undetected, fingerstick monitoring at the frequency he is able to sustain is insufficient to guide safe titration of his mealtime insulin. Plan: prescribe a personal continuous glucose monitoring system with alerts for hypoglycaemia enc/2026-05-19/endocrinology
NBH-ENDO-031-4.2 The most recent hemoglobin A1c result with its collection date, or, where section 3.4 is met by hypoglycaemia rather than by A1c, glucose logs or clinical notes documenting those episodes with dates.	Insufficient documentation Downgraded automatically: the criterion was marked satisfied but no surviving chart evidence supports it. The patient's most recent Hemoglobin A1c result of 8.6% and its collection date of 2026-05-19 are documented in the laboratory results.	No chart evidence cited
NBH-ENDO-031-4.3 A record of device training, or a scheduled training appointment with its date.	Satisfied The record from the diabetes education visit on 2026-06-11 documents that the patient completed a structured training session on using the prescribed continuous glucose monitoring system.	Completed a forty-five minute structured training session with the patient and his spouse on the use, application, calibration and interpretation of the prescribed continuous glucose monitoring system. enc/2026-06-11/diabetes-education
NBH-ENDO-031-6.1 Continuous glucose monitoring for a member with diabetes mellitus who is not treated with insulin, except where section 3.4 is met by documented level 2 hypoglycaemia attributable to a sulfonylurea or meglitinide.	Not satisfied The patient is treated with a multiple daily injection insulin regimen, so this exclusion for members not treated with insulin is not met.	currently on a multiple daily injection regimen: insulin glargine 38 units nightly plus insulin lispro three times daily with meals, four injections per day total enc/2026-05-19/endocrinology Insulin glargine 38 units subcutaneous once nightly med/insulin-glargine Insulin lispro 8-14 units subcutaneous three times daily with meals med/insulin-lispro
NBH-ENDO-031-6.2 Replacement of a functioning device before the end of its manufacturer-stated service life, absent documented loss or irreparable damage.	Not applicable The patient is requesting an initial continuous glucose monitoring system, not a replacement of a functioning device, so this exclusion is not applicable.	No chart evidence cited
NBH-ENDO-031-6.3 More than one personal continuous glucose monitoring system per member concurrently.	Not satisfied The record documents a plan to prescribe a single personal continuous glucose monitoring system, so the exclusion for more than one concurrent system is not met.	Plan: prescribe a personal continuous glucose monitoring system with alerts for hypoglycaemia enc/2026-05-19/endocrinology

Section 3 of 4

The letter that goes out over your name — attempt 2

Subject: Appeal of Coverage Denial for Continuous Glucose Monitoring System - Member ID: NBH-4417-99083 / Claim: CLM-2026-0714-33902

RE: Appeal of Coverage Denial Claim Number: CLM-2026-0714-33902 Member ID: NBH-4417-99083 Service Denied: Continuous glucose monitoring system, receiver and transmitter To Whom It May Concern: This letter constitutes a formal appeal of the coverage denial for the continuous glucose monitoring system for the above-referenced member. The denial stated that the submitted documentation does not establish that the member is treated with an intensive insulin regimen or that self-monitoring of blood glucose has been insufficient to guide therapy. A review of the medical record demonstrates that the applicable criteria under NBH-ENDO-031 are satisfied. 1. Intensive Insulin Regimen (Section NBH-ENDO-031-3.1) Section NBH-ENDO-031-3.1 requires a documented diagnosis of type 1 diabetes mellitus, or type 2 diabetes mellitus treated with an intensive insulin regimen consisting of three or more injections of insulin per day or continuous subcutaneous insulin infusion. The clinical note dated May 19, 2026 documents that the member is a fifty-nine year old man with type 2 diabetes mellitus of nine years' duration on a multiple daily injection regimen consisting of insulin glargine 38 units nightly plus insulin lispro three times daily with meals (four injections per day total), alongside metformin 1000 mg twice daily. This documents type 2 diabetes mellitus treated with four injections per day, satisfying section NBH-ENDO-031-3.1. 2. Device Training (Section NBH-ENDO-031-3.2 and Section NBH-ENDO-031-4.3) Section NBH-ENDO-031-3.2 requires documented completion of a training session on the use and interpretation of the requested device by the member or caregiver, or that such training is scheduled prior to dispensing. Section NBH-ENDO-031-4.3 requires submission of a record of device training or a scheduled training appointment with its date. The record from June 11, 2026 documents that the patient and his spouse completed a forty-five minute structured training session on the use, application, calibration and interpretation of the prescribed continuous glucose monitoring system, satisfying sections NBH-ENDO-031-3.2 and NBH-ENDO-031-4.3. 3. Evaluation Within Six Months (Section NBH-ENDO-031-3.3) Section NBH-ENDO-031-3.3 requires that the member has had at least one in-person or telehealth evaluation with the treating clinician within the six months preceding the request, at which diabetes management was addressed. The medical record documents an evaluation on July 14, 2026 where diabetes management was discussed in full, noting insulin regimen unchanged and fingerstick frequency unchanged at two to three per day, satisfying section NBH-ENDO-031-3.3. 4. Insufficiency of Self-Monitoring (Section NBH-ENDO-031-3.5) Section NBH-ENDO-031-3.5 requires documentation by the prescribing clinician that self-monitoring of blood glucose by fingerstick has been insufficient to guide therapy adjustment, or that the member is unable to perform fingerstick testing at the frequency the treatment plan requires. In the clinical note dated May 19, 2026, the clinician documented: "Because his overnight and mid-shift excursions are going undetected, fingerstick monitoring at the frequency he is able to sustain is insufficient to guide safe titration of his mealtime insulin." This satisfies section NBH-ENDO-031-3.5. 5. Clinical Note Requirements (Section NBH-ENDO-031-4.1) Section NBH-ENDO-031-4.1 requires a clinical note from the treating clinician dated within six months of the request stating the diabetes type, current insulin regimen, and clinical rationale for continuous monitoring. The note dated May 19, 2026 states the diabetes type (type 2 diabetes mellitus), the insulin regimen (insulin glargine 38 units nightly plus insulin lispro three times daily with meals, four injections per day total), and the clinical rationale ("Because his overnight and mid-shift excursions are going undetected, fingerstick monitoring at the frequency he is able to sustain is insufficient to guide safe titration of his mealtime insulin. Plan: prescribe a personal continuous glucose monitoring system with alerts for hypoglycaemia"). This satisfies section NBH-ENDO-031-4.1. Based on the submitted documentation meeting all criteria of medical policy NBH-ENDO-031, we request that the denial be overturned and coverage for the continuous glucose monitoring system be approved.

Requested action: Overturn the denial and approve coverage for the continuous glucose monitoring system.

Every factual claim the letter makes about the patient

These are the sentences you are attesting to. If one of them is not true of this patient, reject the draft rather than co-signing it.

The member is a fifty-nine year old man with type 2 diabetes mellitus of nine years' duration.
The member is currently on a multiple daily injection regimen of insulin glargine 38 units nightly plus insulin lispro three times daily with meals, four injections per day total, alongside metformin 1000 mg twice daily.
On June 11, 2026, the patient and his spouse completed a forty-five minute structured training session on the use, application, calibration and interpretation of the prescribed continuous glucose monitoring system.
On July 14, 2026, diabetes management was discussed in full, noting insulin regimen unchanged and fingerstick frequency unchanged at two to three per day.
On May 19, 2026, the treating clinician documented that because overnight and mid-shift excursions are going undetected, fingerstick monitoring at the frequency the patient is able to sustain is insufficient to guide safe titration of mealtime insulin.
On May 19, 2026, the treating clinician documented a plan to prescribe a personal continuous glucose monitoring system with alerts for hypoglycaemia.

Section 4 of 4

Your co-sign

Waiting on the billing clerk and the ordering clinician. Nothing is transmitted until every required signature is present.

Not signed

Billing clerk

Confirms the paper trail: that the cited sections exist, that the quoted policy text matches its source, and that no claim outruns the matrix.

No approval recorded yet.
Not signed

Ordering clinician

Attests to the clinical argument: that the letter's account of the care and the chart is accurate. A clerk is not in a position to judge this.

No co-sign recorded yet.

Sign the clinical argument in attempt 2

Your signature is pinned to this drafting attempt. If the letter is rewritten afterwards, it does not carry your name until you sign the new one.

Your name Recorded on the case and in the audit log. Required.

Credential MD, DO, NP, PA, and so on. Required.

NPI (optional) Ten digits. Some payers reject an appeal signed without one.

Anything to add (optional) Stored on the case. Not sent to the payer.

Attestation

You are attesting to the medicine, not to the paperwork. Whether every citation resolves and every quotation matches its source is the clerk's confirmation, recorded separately.

I ordered this care, or I am authorised to sign for the clinician who did, and the clinical argument in this letter is accurate.

Recorded with your name, credential and the time, against drafting attempt 2.

If the clinical argument is wrong, do not co-sign it. Say so on the full case record, where the draft can be rejected and rewritten.