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Prepare and Follow Up on a Prior Authorization

Verify what the payer requires, document the case, submit a complete request and follow it through to the person receiving their technology.

Developed and reviewed by the ADCES Diabetes Technology Committee. Last reviewed [Month YYYY]

Before you use it: For educational use. Payer criteria vary by plan and change often. Always verify the current payer policy before submission.

You are on Prepare and Follow Up ← Prior Authorization overview  ·  Respond to a Denial →
Start herePrepare a new requestSteps 1 to 6 Already submittedFollow up on a requestSteps 7 and 8 Request deniedRespond to a denialSeparate page

At any step: Protect continuity. If supplies or treatment are at risk while a request or appeal is pending, consider a clinically appropriate bridge option, such as a manufacturer sample or an over-the-counter biosensor, when appropriate. Provide education on use. Bridge options are not available in every practice or for every technology. Visit the danatech Affordability Tool for assistance programs.

PrepareSteps 1 to 6

1Identify the request

What technology is being requested?

Your choice opens the matching checklist in step 3.

  • Is this a new start, replacement or continued coverage request?
  • Which payer and plan are involved?
  • Which benefit or fulfillment pathway applies, such as the pharmacy benefit or the DME benefit? Glossary
  • Does a prior authorization apply?
If no PA appliesFollow the appropriate ordering or fulfillment process.
If a PA appliesContinue to step 2.

2Verify current coverage criteria

Find the payer's current policy for this technology. Start from the current policy, not memory or a prior submission. Note every clinical, documentation, ordering and administrative requirement.

Confirm three things before you submit
  • Does the person meet the payer's clinical coverage criteria?
  • Does the documentation show that those criteria are met?
  • Are all administrative requirements complete?

A PA may be denied when any one of these is missing, even when the person otherwise qualifies.

Common submission problems that lead to denials
ProblemWhat it means in practice
Insufficient documentation of coverage criteriaPayer coverage criteria and documentation requirements vary by plan and technology. If the clinical record does not include the information required to demonstrate that the person meets the payer's specific coverage criteria, the PA may be denied.
Missing, inaccurate or incomplete diagnosis codingDiagnosis codes should accurately reflect the documented conditions relevant to the coverage request. An incomplete or inaccurate code may prevent the payer from identifying information relevant to its coverage criteria. Coding should be consistent with the clinical documentation submitted with the PA.
Failure to meet payer-specific clinical criteriaCoverage criteria vary by payer, plan and technology and may include requirements related to diagnosis, treatment history, current therapy, clinical documentation or recent visits. Verify the payer's current criteria before submission to determine whether the person meets the requirements for the requested technology.
Incomplete documentation of medical necessityWhen the payer requires documentation of medical necessity, the clinical record should clearly connect the person's relevant clinical history and treatment needs to the requested technology and applicable coverage criteria.
Provider, prescription or administrative documentation gapsMissing required orders, signatures, prescriber information or other plan-specific administrative documentation may delay the PA or result in denial before the clinical criteria are reviewed.

3Compare the criteria with the chart

Compare each payer criterion with what is in the chart, then mark the matching item in the checklist below.

Ready
Documented in the chart and ready to submit
Missing
Absent, out of date or not yet confirmed
N/A
This payer does not require it
A criterion that is not met is not a documentation gap

More chart material will not change it. Discuss with the prescriber whether a medical necessity exception is appropriate or whether another option fits better before you submit.

Documentation checklist

Download printable documentation checklists (PDF) — Black-and-white format with notes and owner columns.

Prompts to check, not requirements

These checklists are prompts to check against the current plan’s policy, not a list of requirements for every request. Do not add testing, trials or documentation only because an item appears here. Mark N/A for anything this plan does not require.

Selections are for this working session and clear when the page reloads. They print.

Continuous Glucose Monitors (CGMs)10 items
  • Diagnosis code(s) reflecting current diabetes type, insulin use and any complications (for example hypoglycemia unawareness or labile glucose)
  • Most recent A1c with date (typically within 3 to 6 months), if required by the payer
  • Documentation of current glucose monitoring frequency, if required by the payer*
  • Insulin regimen: documentation that the person uses insulin (multiple daily injections or pump) or is at risk for hypoglycemia
  • Documented hypoglycemia episodes or significant glucose variability (level 2 or level 3 events preferred)
  • Prescriber order signed by an eligible ordering provider
  • Diabetes education completion or documentation that education is in progress
  • Prior authorization request from the correct payer portal or fax channel
  • Letter of medical necessity (see sample language in step 5)
  • Body weight and BMI if required by the specific payer policy

* Medicare eliminated the four-times-per-day blood glucose testing prerequisite for CGM coverage effective July 18, 2021. Verify the individual payer's current criteria before submitting documentation of prior fingerstick frequency or glucose logs.

Insulin Pumps10 items
  • Documentation of a diagnosis of type 1 diabetes or type 2 diabetes with current insulin treatment
  • Documentation of prior or current insulin therapy and relevant clinical history of diabetes self-management
  • A1c within the required window, with date
  • C-peptide or beta-cell autoantibody testing results, if required by the payer
  • Documented carbohydrate counting ability or diabetes education enrollment
  • Documentation of glucose monitoring frequency, as specified by the individual payer
  • Prescriber order from a qualifying provider (some payers require specific credentials when ordering)
  • Pump therapy training plan or confirmation of availability
  • Letter of medical necessity with narrative on MDI history (see sample language in step 5)
  • Documented hypoglycemia history with dates, if applicable

Coverage note: C-peptide and beta-cell autoantibody testing are not recommended as prerequisites for initiating insulin pump or AID therapy under the ADA Standards of Care in Diabetes—2026. However, some payers require this testing for coverage. Verify the specific plan's requirements before ordering tests or submitting documentation.

Automated Insulin Delivery (AID) Systems15 items

Shared with insulin pumps

  • Documentation of a diagnosis of type 1 diabetes or type 2 diabetes with current insulin treatment
  • Documentation of prior or current insulin therapy and relevant clinical history of diabetes self-management
  • C-peptide or beta-cell autoantibody testing results, if required by the payer
  • Documented carbohydrate counting ability or diabetes education enrollment
  • Documentation of glucose monitoring frequency, as specified by the individual payer
  • Pump therapy training plan or confirmation of availability
  • Documented hypoglycemia history with dates, if applicable

Additional for AID

  • Documentation of prior insulin pump use and duration, if applicable or required by the payer
  • CGM use history and experience with glucose data interpretation
  • A1c within the required window demonstrating suboptimal control or persistent hypoglycemia despite pump therapy
  • Caregiver or person's training capability confirmed in the chart
  • Prescriber order from a qualifying provider (some payers require specific credentials when ordering)
  • Documentation that the specific AID system is FDA-cleared for the person's indicated use
  • Integration compatibility confirmed between pump and CGM components
  • Letter of medical necessity with clinical rationale for closed-loop therapy

Coverage note: C-peptide and beta-cell autoantibody testing are not recommended as prerequisites for initiating insulin pump or AID therapy under the ADA Standards of Care in Diabetes—2026. However, some payers require this testing for coverage. Verify the specific plan's requirements before ordering tests or submitting documentation.

Coverage note: Prior use of a conventional insulin pump is not a prerequisite for initiating AID therapy under the ADA Standards of Care in Diabetes—2026. Some payers may request documentation of prior pump use or treatment history. Verify the specific plan's requirements before submitting documentation.

Smart Insulin Pens8 items
  • Diagnosis code(s) reflecting insulin-requiring diabetes
  • Documentation of current insulin regimen and delivery method
  • Documentation of the clinical rationale for the requested smart insulin pen
  • Most recent A1c with date
  • Prescriber order for the specific smart pen or system
  • Documentation of dose titration history, dosing data capture or other clinical rationale for the requested smart insulin pen
  • Connectivity capability confirmed (smartphone app compatibility)
  • Letter of medical necessity or additional clinical documentation supporting the requested smart insulin pen or system

4Close documentation gaps

Work through every item marked Missing in Step 3 before submitting. Identifying and addressing documentation gaps before submission can help prevent delays, requests for additional information, and denials.

Optional AI help

Before you use AI

AI tools do not have access to the chart unless you provide the data. Do not enter protected health information (PHI) into a general AI tool unless your organization has approved that tool for PHI. Otherwise, remove or de-identify patient information and follow your organization's privacy, security and AI-use policies. Always review and verify AI output before using it in a submission.

AI promptFind documentation gaps before submission

I am preparing to submit a prior authorization for [technology] for a patient with [payer name]. The payer's clinical criteria are: [paste criteria]. Here is the documentation I currently have: [paste current documentation]. Identify any gaps between the payer's stated criteria and my current documentation, and tell me what additional information I need to collect or document before submission.

Follow these rules: Use only the information I provide. Do not invent clinical facts, payer requirements, dates, outcomes or citations. If required information is missing, list the gap rather than filling it in. Do not state that a coverage criterion is met unless the documentation I provide supports it. Use only payer criteria or clinical references I provide.

Click the text to select it, then copy.

5Write the letter of medical necessity

Add a letter when the payer requires documentation of medical necessity. The clinical team usually drafts it, within role and organizational policy, and the prescriber reviews and signs it.

A strong letter connects three things
  1. The requested technologyWhat is being requested and why now
  2. The payer's criteriaEach criterion this person meets, in the payer's own terms
  3. The evidenceDated values, events, prior interventions and outcomes, in chronological order

Lead with the patient's story, not just the diagnosis. Build a chronological clinical narrative using the person's own values, dates and events rather than general statements. Specificity strengthens a PA; generality weakens it.

Start from a sample statement

Starting points, not text to copy

Use a sentence only if every statement in it is accurate, documented in the chart and true for this person. Remove any claim the record does not support, such as reduced hypoglycemia or improved outcomes.

Choose the statement that matches the request, then adapt it to the individual. Your technology choice in step 1 opens the matching one.

By technology
CGMMedical necessity for CGM[Patient name] is a [age]-year-old with [diagnosis] managed on [insulin regimen]. Despite consistent self-monitoring...

[Patient name] is a [age]-year-old with [diagnosis] managed on [insulin regimen]. Despite consistent self-monitoring [with fingerstick glucose testing [frequency] times daily, if required by the payer], [he/she/they] continues to experience [glycemic variability / recurrent hypoglycemia / suboptimal A1c]. A continuous glucose monitor is medically necessary to provide real-time glucose data, reduce hypoglycemic exposure and support clinical decision-making in a way that intermittent fingerstick monitoring is unable to achieve.

Click the text to select it, then copy.
PumpMedical necessity for an insulin pump[Patient name] has been managed on a multiple daily injection regimen of [insulin types and doses] for [duration]....

[Patient name] has been managed on a multiple daily injection regimen of [insulin types and doses] for [duration]. Despite optimized MDI therapy and ongoing diabetes education, [he/she/they] continues to experience [A1c above target / frequent hypoglycemia / significant glucose variability]. Insulin pump therapy is medically necessary to provide precise basal rate titration, reduce hypoglycemic burden and improve overall glycemic outcomes that have not been achievable with MDI.

Click the text to select it, then copy.
By clinical reason
ReasonDocumented hypoglycemia risk[Patient name] has experienced [number] hypoglycemic events in the past [timeframe], including [number] level 2...

[Patient name] has experienced [number] hypoglycemic events in the past [timeframe], including [number] level 2 events (glucose below 54 mg/dL) and [number] events requiring third-party assistance. Hypoglycemia unawareness has been documented by [provider] on [date]. Real-time CGM with customizable low glucose alerts is medically necessary to reduce the risk of severe hypoglycemia and the associated morbidity.

Click the text to select it, then copy.
ReasonGlucose variabilityDespite an A1c of [value], [patient name]'s glucose management is characterized by significant intraday variability,...

Despite an A1c of [value], [patient name]'s glucose management is characterized by significant intraday variability, with rapid glucose excursions that are not captured by A1c or fingerstick monitoring alone. [He/She/They] reports [symptoms associated with variability: fatigue, difficulty concentrating, hypoglycemic episodes, etc.]. Continuous glucose monitoring is necessary to identify the magnitude, frequency and pattern of these excursions to guide therapeutic adjustments.

Click the text to select it, then copy.
ReasonTreatment intensification[Patient name]'s current regimen has been progressively intensified over the past [timeframe], including [list...

[Patient name]'s current regimen has been progressively intensified over the past [timeframe], including [list interventions: medication adjustments, dietary intervention, education]. Despite these interventions, [specific clinical marker] remains above target. The addition of [technology] is the clinically appropriate next step in the treatment intensification pathway and is consistent with current ADA and AACE standards of care for [patient's indication].

Click the text to select it, then copy.

Optional AI help for drafting

Each prompt includes its safety rules, so copy the whole block. See Before you use AI in step 4.

AI promptDraft a letter of medical necessity

Write a letter of medical necessity for continuous glucose monitor (CGM) approval for a patient with the following clinical details: [paste diagnosis, A1c, insulin regimen, hypoglycemia history, monitoring frequency and any documented complications]. The letter should connect the patient's clinical history to the medical necessity for CGM, explain the clinical benefits of CGM for this individual, including the limitations of intermittent fingerstick monitoring when relevant to the person's clinical circumstances and the payer's criteria, and reference current ADA standards of care. Use a formal clinical tone appropriate for payer submission.

Follow these rules: Use only the information I provide. Do not invent clinical facts, payer requirements, dates, outcomes or citations. If required information is missing, list the gap rather than filling it in. Do not state that a coverage criterion is met unless the documentation I provide supports it. Use only payer criteria or clinical references I provide.

Click the text to select it, then copy.
AI promptOrganize clinical data into a PA narrative

I need to write a prior authorization narrative for [technology type]. Here is the patient's clinical data: [paste relevant chart notes, labs, device reports (if applicable) and visit documentation]. Organize this information into a chronological clinical summary that leads with the patient's diagnosis and progression, documents prior interventions and outcomes, highlights key clinical events with dates, and concludes with a clear statement of medical necessity. Do not add clinical information that is not in the data I provided.

Follow these rules: Use only the information I provide. Do not invent clinical facts, payer requirements, dates, outcomes or citations. If required information is missing, list the gap rather than filling it in. Do not state that a coverage criterion is met unless the documentation I provide supports it. Use only payer criteria or clinical references I provide.

Click the text to select it, then copy.

6Build and check the submission

Assemble the request with the letter attached, then check it before you send it.

Submission check

Check each item as you complete it. Checkmarks clear when the page reloads.

Submit and follow upSteps 7 and 8

7Submit and follow up

Record these details when you submit, and keep them where the whole team can find them, such as the EHR or your practice's secure tracking system.

  • Technology and payer / plan
  • Submitted on
  • Confirmation or reference number
  • Follow-up owner
  • Expected response date
  • Next follow-up date
  • Additional information requested (what, deadline, date sent)
  • Decision and date
  • Authorization dates
  • Approved items or quantities
  • Order processed by pharmacy or supplier (date)
  • Received by the person (date)
Use these fields in your EHR note or tracking log.
If the payer requests more information

Identify exactly what is being requested, note the deadline, respond within the required timeframe and record the date sent.

8AIf approved: follow through to the person

  • Notify the person and relevant care team members
  • Document the approval, the authorization dates and the approved items or quantities
  • Complete ordering or fulfillment steps
  • Confirm the pharmacy or supplier has processed the order
  • Confirm the person has received the technology or supplies. The request is complete at this point, not at approval.
  • Set renewal or continued-coverage reminders

Renewal tracking systems in Build a PA-Ready Practice →

8BIf denied: identify the reason first

Do not automatically resubmit the same information. A denial may involve more than one issue, and the reason decides the response: a correction, a clarification, a different submission pathway or an appeal.

Review response options in Respond to a Denial →

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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.

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