Prior Authorization Request (Diabetes Device/Supplies)

Prior Authorization Request – Diabetes Device/Supplies

Patient Name: [Patient full name]

DOB: [Date of birth]

MRN: [Medical record number]

Insurance/Plan: [Payer name and plan]

Request Type: [new start / renewal / replacement / appeal / supplies only]

Prescribing Clinician: [Name, credentials, NPI, clinic contact]

Date of Request: [Date]

Date of Last Diabetes-Focused Visit: [Date] (Do not leave blank; if not yet completed, state "Pending scheduled for [date]")

(Label information sources throughout and include dates/data windows for all objective evidence. For coverage-critical elements—training status, recent visit, C-peptide for pump, hypoglycemia documentation—do not leave blanks; use "Pending [expected date]" or "Not yet documented; will obtain." Do not assert criteria are met without explicit documentation.)

Medical Necessity Summary

• [Diabetes type with ICD-10 code and duration] (Source: [EHR problem list / outside records])
• [Current regimen and monitoring method, e.g., MDI/pump, rtCGM/isCGM/BGM only] (Source: [EHR medication list / CGM download / patient report])
• [Primary safety concern or clinical indication: severe hypoglycemia risk / hypoglycemia unawareness / nocturnal lows / glycemic variability / suboptimal A1C despite optimization]
• [Key objective data supporting necessity: A1C trend, CGM TIR/TBR, documented hypoglycemia events with dates/values] (Sources cited)
• [Specific device requested and expected clinical/safety benefit]
• [Training and readiness status: Completed / Scheduled / Not yet documented] (Trainer: [program/clinician]; Date: [date])

Clinical Background

• Diagnosis: [Diabetes type] (ICD-10: [code]); Date of diagnosis: [date]; [Etiology if atypical: pancreatectomy / LADA / CF-related / other] (Source: [EHR / outside records])
• Complications/Comorbidities: [CKD, pregnancy, neuropathy, gastroparesis, CVD, cognitive impairment, visual impairment, other] (Source: [EHR / specialist notes])
• Pertinent Social/Safety Factors: [Living situation, driving/occupation hazards, shift work, caregiver involvement] (Source: [patient / caregiver report])

Current Diabetes Management

• Insulin regimen: [MDI / pump]. Basal: [insulin name, dose, timing]. Bolus: [insulin name] with ICR [ratio] and ISF [value] or [typical dosing pattern]. Dose adjustments: [frequency and by whom]. (Source: [EHR medication list / pump download / patient report])
• Non-insulin agents: [Name, dose, frequency for each] (Source: [EHR medication list])
• Glucose monitoring: [rtCGM / isCGM / BGM only]. If CGM: [brand/model], alerts [settings], data sharing [yes/no]. If BGM: prescribed [frequency/day] vs actual [frequency/day]. (Source: [CGM download / BGM log / patient report]; Data window: [dates])
• Adherence barriers and mitigation: [Identified barriers] and [planned supports/education/technology features] (Source: [patient/caregiver report / DSME notes])

Prior Therapy Attempts

(Include when step therapy documentation is required.)

• Prior device use: [CGM / pump], [brand/model], [start–stop dates], [clinical outcomes], [reason discontinued] (Source: [device downloads / clinic notes])
• Non-device optimization attempts: [Intervention: MDI optimization / carb counting education / insulin titration / hypoglycemia mitigation strategies], [date], [result] (Source: [clinic notes / DSME certificate])

Objective Glycemic Data

A1C History (Include at least two most recent values if available)

Date	Value	Source
[date]	[A1C %]	[lab / EHR / outside record]
[date]	[A1C %]	[lab / EHR / outside record]

CGM Summary (Include if CGM data available)

• Data window: [start date] to [end date]; CGM active: [percent]% (Source: [CGM/AGP report])
• Mean glucose: [value] mg/dL; GMI: [percent]% (if available); %CV: [percent]%
• Time in range 70–180 mg/dL: [percent]%
• Time below range 54–69 mg/dL: [percent]%; Time below 54 mg/dL: [percent]%
• Time above range 181–250 mg/dL: [percent]%; Time above 250 mg/dL: [percent]%
• Clinician interpretation: [Brief interpretation prioritizing hypoglycemia patterns first, then hyperglycemia/variability; reference specific patterns or times as applicable]

BGM Summary (Include if no CGM)

• Prescribed frequency: [value]/day; Actual frequency: [value]/day (Source: [BGM log / patient report]; Data window: [dates])
• Representative values/patterns: [Brief summary with ranges and timing patterns]

Acute Glycemic Events (Include if relevant)

• Level 3 hypoglycemia (severe): [date], glucose [value if known], third-party assistance required: [yes / no], outcome: [ED / EMS / hospitalization / recovery at home] (Source: [ED/EMS record / patient/caregiver report])
• Level 2 hypoglycemia (<54 mg/dL): [date, value]; [date, value] (Source: [CGM download / BGM log])
• Hyperglycemic crisis: [DKA / HHS], [date], [hospitalization details] (Source: [hospital record])

Clinical Rationale

[Concise justification for medical necessity prioritizing: (1) safety concerns—prevention of severe hypoglycemia, impaired awareness, nocturnal events—supported by objective data; (2) anticipated improvement in outcomes with requested device; (3) patient readiness and feasibility; (4) inadequacy of alternatives attempted. Explicitly cite data, dates, and sources from Objective Glycemic Data section. Do not infer—include only documented facts.]

Requested Device/Supplies

• Item 1: Category: [rtCGM / isCGM / insulin pump / AID system]; Brand/Model: [name]; Components: [sensors / transmitter / receiver / infusion sets / reservoirs / pods]; Quantity: [units per 30 or 90 days]; Request type: [new start / renewal / replacement]
• Item 2: [Additional components/supplies as needed with same details] (Omit if not applicable)

Coverage Criteria Documentation

(Include only the module(s) relevant to the requested device. For coverage-critical items, do not leave blanks—use "Pending [date]" or "Not yet documented; will obtain.")

CGM Module

• Diabetes diagnosis confirmed: [Type] (ICD-10: [code]) (Source: [EHR / outside records])
• Insulin-treated: [yes / no]. If yes: [MDI / pump; regimen details]. If no: complete Problematic Hypoglycemia Pathway below. (Source: [EHR medication list])
• Training status: [Completed / Scheduled / Not yet documented; will obtain]; Date: [date]; Trainer: [name/program] (Coverage-critical)
• Diabetes-focused visit within 6 months prior to ordering: [yes / no / pending]; Date: [date]; Provider: [name] (Coverage-critical)
• For continued coverage: CGM adherence [yes / no], [percent]% active over [date range]; Diabetes control evaluated at visit [yes / no]; Visit date: [date]

Problematic Hypoglycemia Pathway

(Use if non–insulin-treated or as additional support. Document one of the following.)

• Option A: ≥2 Level 2 events (<54 mg/dL): [date, value]; [date, value]. Prior adjustments before most recent event (≥2 required): [adjustment #1, date, result]; [adjustment #2, date, result].
• Option B: ≥1 Level 3 event with third-party assistance required: [date], glucose [value if known], assistance: yes, outcome: [ED / EMS / hospitalization].
• Sources: [CGM download / BGM logs / ED or EMS records / patient/caregiver report] (Coverage-critical—do not leave blank if using this pathway)

Insulin Pump Module

• C-peptide: [value] ng/mL; Date: [date]; Concurrent fasting glucose: [value] mg/dL; Lab: [name]. If pending: "Ordered [date], results pending" (Coverage-critical for Medicare; document at least once)
• Diabetes self-management education: [Completed / Scheduled / Pending]; Date: [date]; Program: [name] (Coverage-critical)
• MDI history ≥3 injections/day for ≥6 months: [yes / no]; Duration: [months] (Source: [EHR / clinic notes]) (Coverage-critical)
• Glucose monitoring ≥4 checks/day for prior 2 months: [yes / no]; Method: [BGM / CGM]; Evidence: [BGM logs / CGM percent active over dates] (Coverage-critical)
• Qualifying indication: [A1C above target / recurrent hypoglycemia / wide glucose excursions / dawn phenomenon]; Supporting data: [reference specific values/dates from Objective Glycemic Data] (Coverage-critical)
• For replacement only: Reason: [device failure / expired warranty / upgrade for safety]; Prior pump benefit: [outcomes summary with data] (Source: [pump download / clinic notes])

AID System Module

• Patient/caregiver readiness to respond to alarms, troubleshoot, upload data: [yes / no]; Details: [brief assessment] (Coverage-critical)
• Indication for automation beyond pump alone: [persistent hypoglycemia risk / variability despite optimized therapy / need for predictive suspend]; Supporting data: [CGM metrics/events with dates]
• CGM integration: Current/planned CGM [brand/model]; Compatible with requested AID: [yes / no] (Source: [CGM download]; Data window: [dates])
• Patient age: [years] (Some systems have age-specific criteria)

Training and Follow-Up Plan

• Training: [Completed / Scheduled / Not yet documented; will obtain]; Date: [date]; Trainer: [name/program]
• Safety plan: Hypoglycemia treatment protocol reviewed: [yes / no]; Glucagon available: [yes / no]; Backup monitoring (BGM) and insulin delivery (MDI) if device fails: [yes / no]
• Follow-up schedule: CGM users: visit at least every 6 months documenting adherence. Pump/AID users: evaluation at least every 3 months. Next visit: [date]
• Data plan: Upload/share data via [platform]; Review at follow-up will reassess [TIR / TBR / A1C / hypoglycemia events / adherence]

Attachments

• AGP/CGM download report (data window [dates]): [Attached / Available on request]
• BGM logs ([date range]): [Attached / Available on request]
• A1C lab results: [Attached / Available on request]
• Hypoglycemia event documentation (ED/EMS records): [Attached / Available on request / Not applicable]
• Diabetes education certificate: [Attached / Available on request]
• Prior denial letter (if appeal): [Attached / Not applicable]
• Relevant visit notes: [Attached / Available on request]

Attestation

The requested diabetes device/supplies are medically necessary for ongoing diabetes management and safety. The information above reflects the contemporaneous medical record and objective data available at the time of this request.

Provider Signature: [Signature]    Date: [Date]

Printed Name/Credentials: [Name, credentials]    NPI: [NPI]    Contact: [Phone, fax, address]