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For diabetes care teams

Prior Authorization for Diabetes Technology

Practical resources for care teams preparing diabetes technology PAs, responding to denials and building systems that make the next request easier.

Use them to confirm what a payer requires, document the case, follow up on the request and keep the person supported while a decision is pending.

Developed and reviewed by the ADCES Diabetes Technology Committee. Last reviewed October 2026

Where are you in the process?

Preparing a request

Verify payer criteria, document the case and follow the request through to the person receiving their technology.

Prepare a request →

Responding to a denial

Identify the reason and choose the appropriate response.

Review response options →

Setting up your practice

Templates, roles and renewal tracking that make the next request easier.

Build a PA-ready practice →

How a PA moves

An overview. Full instructions and checklists are on the linked pages.

PrepareSteps 1 to 6
  1. 1
    Identify the requestTechnology, request type, payer, plan and benefit pathway
  2. 2
    Verify current coverage criteriaStart from the current policy, not memory or a past submission
  3. 3
    Compare criteria with the chartMark each item ready, missing or N/A. A criterion that is not met is not a documentation gap.
  4. 4
    Close documentation gapsAddress missing information before you submit
  5. 5
    Write the letter of medical necessityConnect the technology, the payer's criteria and the evidence
  6. 6
    Build and check the submissionForms, order, signatures, channel and a final check
Prepare and follow up on a PA →
Submit and follow upSteps 7 and 8
  1. 7
    Submit and follow upRecord the reference number, owner and follow-up dates. If the payer asks for more information, send exactly what is requested within its timeframe.
  2. 8A
    Approved: follow through to the personDocument the approval and authorization dates, confirm the order is processed and the person receives the technology, then set renewal reminders
  3. 8B
    Denied: identify the reason firstA denial may involve more than one issue. The reason decides the response: correction, clarification, a different pathway or an appeal.
Review response options →

At every step, protect continuity: If supplies or treatment are at risk while a request or appeal is pending, consider whether a clinically appropriate bridge option is available, such as manufacturer samples or assistance programs that may provide products at no or reduced cost. Provide education on use when appropriate. Availability and eligibility vary by manufacturer, product, and program. Visit the danatech Affordability Tool for information on available assistance programs.

For practice leads and managers

Build a PA-ready practice

Set up four components so every request has the right information, a clear owner and a next step.

See the four componentsDownload the workbook (Excel, .xlsx)
  • Payer criteria sheetOne current reference for your most common plans
  • Documentation templatesSmart phrases and an approved LMN shell
  • Renewal trackingEvery deadline, including continued-coverage requirements
  • Roles and handoffsAn owner and backup for every task
Case study

From denial to approval

“The instinct with a denial is to send more.”

Barrier
The plan covered CGM only for members on insulin, a sulfonylurea or a meglitinide. The patient met none of them. Criterion not met
Approach
Requested a medical necessity exception on clinical grounds the criterion did not capture, marked urgent, with peer-to-peer as a fallback.
Outcome
Approved on expedited written review within 72 hours.
Read the full case study →
Prior Authorization Knowledge Check

A person changed health plans and needs CGM sensors. You have last year’s approved request. What do you do first?

Try 11 scenarios →About 6 minutes. See where to focus before you read the guide.

The clinicians behind these resources

  • Paola Acevedo, PharmD, CDCES, BC-ADM
  • Hayley Sewell, PharmD, BCACP
  • Alexander Maciejewski, PharmD, MS, AAHIVP
  • Russender Powell, MS, RD, LD, BC-ADM, CDCES
  • Katharine Patel, MS, RD, LDN, BC-ADM, CDCES
  • Melanie Teslik, RN, MS, BC-ADM, CDCES, CPHQ
  • Cassie Moffitt, PhD(c), MSN Ed, RN, CDCES, CNE, ACUE
Meet the Diabetes Technology Committee →

Watch and listen

The webinar and podcast these resources were built to accompany.

Navigating Prior Authorization for Diabetes Technology: A Roundtable Discussion, with four roundtable participants
Webinar

Navigating Prior Authorization for Diabetes Technology: A Roundtable Discussion

The live session these resources were built to accompany.

Watch the recording
Diabetes Care Conversations podcast artwork featuring a speaker and the ADCES logo
Podcast

Diabetes Care and the Marketplace: What's Ahead

Listen in as Amy Killelea, Assistant Research Professor at Georgetown University's Center on Health Insurance Reforms, discusses how upcoming policy changes could affect diabetes coverage, costs and access to care.

Listen to the episode

All resources in this section

Review cycleReviewed annually and when major payer policy changes occur.
Before you use itFor educational use. Payer criteria vary by plan and change often. Always verify the current payer policy before submission.

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DISCLAIMERS: 

This site and its services do not constitute the practice of medical advice, diagnosis or treatment. Always talk to your diabetes care and education specialist or health care provider for diagnosis and treatment, including your specific medical needs. If you have or suspect that you have a medical problem or condition, please contact a qualified health care professional immediately. To find a diabetes care and education specialist near you, visit the ADCES finder tool.

ADCES and danatech curate product specifics and periodically review them for accuracy and relevance. As a result, the information may or may not be the most recent. We recommend visiting the manufacturer's website for the latest details if you have any questions.

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