Prior Authorization Request (Diabetes Technology)

Prior Authorization Request

Date: [Date]

Payer/Plan Name: [Payer/Plan Name]

Member Name: [Patient full name as on insurance plan]

Date of Birth: [DOB]

Member ID: [Member ID]

Request Type: [Initial PA / Renewal / Appeal]; [Standard / Expedited]

Prescriber: [Prescriber name, credentials, NPI, clinic address, phone/fax]

Clinical Contact for Follow-up: [Contact name and direct line]

Subject Line and Executive Summary

Subject: Prior Authorization Request – [CGM / Insulin Pump / AID] for [Patient Name], DOB [DOB]

[Executive summary – 4–8 lines stating: diabetes diagnosis/type and insulin status; current regimen and monitoring method; key risk problem(s) driving need such as recurrent hypoglycemia, nocturnal lows, hypoglycemia unawareness, severe variability, high-risk occupation, pregnancy, or pertinent comorbidities; device(s) requested; and targeted clinical outcomes] (Lead with why this request is medically necessary for this specific patient. Use time-anchored language such as "in the past X days" or specific dates.)

Patient Clinical Profile

Primary diagnosis: [Diabetes type/status and duration] (If type uncertain, describe what is known, e.g., "insulin-deficient diabetes on basal-bolus regimen" without inferring etiology.)

Key comorbidities affecting technology need/safety: [Relevant comorbidities such as CKD, pregnancy, cognitive/vision/dexterity limitations, cardiac disease] (Omit if none relevant.)

Diabetes complications: [Retinopathy / nephropathy / neuropathy / hypoglycemia unawareness / other] (Only include if documented; omit section if none.)

Care context: [Caregiver involvement, work or school constraints, living situation] (Include only if relevant to training or support needs.)

Current Diabetes Treatment and Monitoring

• Insulin regimen: [MDI / Pump]; [Basal insulin name, dose, timing]; [Bolus insulin name and dosing method]; [Frequency of regimen adjustments]
• Non-insulin agents: [Medications and doses] (Note agents with hypoglycemia risk such as sulfonylureas or meglitinides.)
• Glucose monitoring: [SMBG frequency and reliability]; [Prior CGM use: device, wear time/dates, reason for discontinuation if applicable]
• Adherence barriers CGM or pump could mitigate: [Barriers such as fingerstick burden, work constraints, inability to detect nocturnal lows, vision/dexterity issues]

Objective Glycemic Data Summary

(Include the most objective data available with specific dates or ranges. Separate facts from interpretation.)

• CGM download: [Date range]; Time-in-range [%] (70–180 mg/dL); Time-below-range [%] (<70 mg/dL); Time <54 mg/dL [%]; Mean glucose [mg/dL]/GMI [%]; CV [%]; Wear time [%] (Include if CGM data available.)
• Meter download summary: [Date range]; Average glucose [mg/dL]; Testing frequency [tests/day]; Documented lows [values and dates] (Include if no CGM data available.)
• Patient log: [Specific glucose values with dates/times, including lows] (Include if no downloads available.)
• Most recent HbA1c: [Value] on [date]; [Trend over prior results] (If unavailable, state: "HbA1c not available within past X days; ordered on [date].")
• Acute care utilization: [ED visits or hospitalizations related to hypoglycemia or hyperglycemia with dates and brief outcomes] (Omit if none.)

Hypoglycemia Risk and Safety

(Include this section only if hypoglycemia is part of the medical necessity argument. Omit entirely if not applicable.)

• Hypoglycemia awareness status: [Intact / Impaired]; [Reported symptoms or absence of warning symptoms]
• Nocturnal hypoglycemia: [Concern present / absent] with [supporting facts]
• High-risk circumstances: [Driving / operating machinery / living alone / pregnancy / seizure history / other]
• Documented Level 2 events (<54 mg/dL): [Dates, values, context]; [Persistence despite regimen adjustments]
• Documented Level 3 events (requiring third-party assistance): [Dates]; [Who assisted]; [Actions taken such as glucagon or EMS]; [Outcome]

(Clearly distinguish documented events from clinical inference about increased risk. If no hypoglycemia history and this is confirmed, state: "No documented hypoglycemia events in the past X months.")

Prior Trials and Alternatives Considered

• SMBG optimization: [Increased testing frequency, log review, diabetes education] with [dates] and [outcomes]
• Medication/regimen adjustments: [Changes with dates] and [effects on A1c, TIR, lows, or variability]
• Prior CGM or pump/AID trial: [Device, dates, wear time/utilization]; [Reason for discontinuation or coverage loss] (Include if applicable.)
• Why alternatives are inadequate: [Patient-specific safety, outcome, or feasibility limitations] (Tie to documented risks/outcomes; avoid generic statements.)

Requested Technology

• Device category: [Personal CGM adjunctive / non-adjunctive] and/or [Insulin pump tubed / tubeless] and/or [AID / hybrid closed-loop]
• Brand/model: [Device name/model]; [Reason specific features are medically necessary] (Include only if payer-required or specific features are necessary.)
• Display/communication: [Receiver / smartphone / data sharing features] (Include if relevant to coverage or safety plan.)
• Supplies requested: [Sensors, infusion sets, cartridges, quantities, and duration]
• New start or replacement: [New start / Replacement]; [Reason for replacement] (Include replacement reason if applicable.)

Training and Competency Plan

• Training status: [Completed / Scheduled / In progress] on [dates] with [trainer role and credentials such as CDCES, endocrine RN, or device trainer] (Do not imply completion if training is not yet completed.)
• Patient/caregiver competency: [Cognitive ability to learn and use device]; [Vision/dexterity status and accommodations if needed]; [Willingness and adherence plan]
• Data review and follow-up plan: [How downloads will be reviewed]; [Who will adjust therapy]; [Follow-up interval for troubleshooting and ongoing management]

Clinical Rationale

(Provide individualized reasoning tied to documented risks and outcomes. Present expected outcomes as reasonable expectations, not guarantees. For CGM-only requests, omit pump/AID rationale. For pump/AID-only requests, include hypoglycemia/variability justification. For renewals, emphasize adherence, utilization/wear time, and objective benefit since initiation.)

CGM rationale: [Why CGM is needed for this patient's safety and outcomes—prevention/detection of hypoglycemia, nocturnal lows, impaired awareness, alarm features, data sharing capability; expected improvements in time-in-range, A1c, or variability; reduction in monitoring burden] (Include for CGM requests.)

Pump/AID rationale: [Why CSII or AID is clinically appropriate—severe glycemic excursions, dawn phenomenon, difficulty meeting goals on MDI, recurrent hypoglycemia; why requested configuration is necessary] (Include for pump/AID requests.)

Patient-specific measurable expected benefits: [2–4 specific goals such as: reduce time <54 mg/dL, increase time-in-range toward X%, reduce severe hypoglycemia events, improve A1c toward individualized goal of X%, reduce glycemic variability]

Attachments

• [Recent diabetes clinic notes supporting medical necessity (date range)]
• [CGM download report (AGP/standardized) or meter download/log (date range)]
• [Most recent HbA1c and pertinent labs with dates]
• [Documentation of hypoglycemia events with dates] (If applicable.)
• [Education/training documentation] (If available.)
• [Prescription/order and DME supplier details] (If applicable.)

Closing

Please approve coverage for the requested device(s) and supplies as detailed above. I am available for peer-to-peer review at [best contact number] during [preferred contact times].

I attest that the information provided is accurate and reflects the contemporaneous medical record for this patient.

Treating Clinician Signature: [Name, credentials] | NPI: [NPI] | Date: [Date]