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Respond to a Prior Authorization Denial

A denial can often be reconsidered, appealed or corrected. Identify the reason first, then choose the response that fits it.

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

Before you use it: For educational use. Appeal rights, timelines and processes vary by payer and plan. Always follow the instructions in the denial letter and the payer's current policy.

DENIED
You are on Respond to a Denial ← Prior Authorization overview
Just deniedStart with the denial letterSteps 1 to 4 EscalatingExpedited review or peer-to-peerStep 5

Protect continuity while you respond.A denial can leave the person without supplies or treatment. When clinically appropriate and available, consider a bridge option such as a manufacturer sample or an over-the-counter option, with education on use. Bridge options are not available in every practice or for every technology; view Affordability Tool for assistance programs.

Respond to a denialSteps 1 to 6

1Read the denial letter in full

The denial letter contains the payer's specific reason for denial. It is your roadmap. Before drafting anything or requesting a peer-to-peer, identify exactly which criterion was not met and what documentation the payer says was missing or insufficient.

Also note from the letter
  • The deadline to request reconsideration or file an appeal
  • Whether expedited review is available and how to request it
  • The submission channel the payer requires for a response

2Identify the reason before you respond

Do not automatically resubmit the same information. Name the type of denial first, because each type calls for a different response. A denial may involve more than one of these.

Denial letterWhat is the stated reason?

Documentation gap

Looks likeSomething required was missing or insufficient.

Typical responseSupply the missing element and request reconsideration. Address the stated gap directly rather than repeating the original request.

Coverage criterion not met

Looks likeThe person does not meet a stated coverage criterion. More documentation will not change it.

Typical responseRequest a medical necessity exception on clinical grounds the criterion does not capture. Do not argue that the criterion is met. See the case study

Administrative or submission issue

Looks likeWrong submission pathway, missing signature, prescriber requirement or incorrect form.

Typical responseCorrect the issue and resubmit through the right pathway.

Medical necessity disputed

Looks likeThe payer does not agree the technology is medically necessary based on what was submitted.

Typical responseAppeal with a criteria-matched clinical narrative. Consider peer-to-peer review (step 5).

3Get the payer's clinical policy

Identify the payer's current clinical coverage policy or applicable criteria for the requested technology. It may be on the payer's provider portal or available directly from the payer. Review the criteria and documentation requirements before preparing a response, and use them as a checklist so each requirement is addressed.

Depending on the payer and technology, criteria may address diagnosis, current treatment, laboratory or glucose data, prior therapies, education or training, and other clinical requirements. Knowing them lets you build a targeted, criteria-matched response rather than a general clinical summary.

When a criterion is not met

Identify what it is standing in for. In the case study, the care team read a requirement for insulin, a sulfonylurea or a meglitinide as a proxy for hypoglycemia risk, which did not reflect that person's actual need.

See the case study

4Build the response

Address the specific reason for denial first. A response that does not answer the stated reason is rarely successful. Then present the clinical evidence chronologically:

  • When the diagnosis was established and how it has progressed
  • Which relevant interventions were tried, in what order and with what documented outcomes
  • Which clinical events (hypoglycemia, high A1c, variability) are documented, and when
  • What the requested technology will change clinically, and why alternatives are insufficient

This structure also mirrors how a peer-to-peer conversation flows, so it prepares the prescriber if one is needed.

Need help with the letter itself? See Write the letter of medical necessity on Prepare and Follow Up.

From the case study
  • Address facts that cut against you directly instead of leaving them out.
  • For an established device user, show benefit already demonstrated (glycemic metrics, wear time, decisions the data informed) rather than predicted benefit.
  • Attach evidence as labeled exhibits, with captions that carry the key numbers in text.
Optional AI help

Copy the whole block; it includes its safety rules. Do not enter PHI into a general AI tool unless your organization has approved it. Always verify AI output.

AI promptDraft an appeal letter after a denialA prior authorization for [technology] was denied for the following reason: [paste exact denial language]. The...

A prior authorization for [technology] was denied for the following reason: [paste exact denial language]. The patient's clinical information is: [paste relevant data]. Write a formal appeal letter that directly addresses the stated denial reason, aligns the patient's clinical documentation with the payer's criteria, and requests reconsideration. Include a brief statement requesting peer-to-peer review if the written appeal is not approved.

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.

5Escalate when the facts support it

Peer-to-peer review

When peer-to-peer (P2P) review is available, decide whether it fits the reason for denial, the payer's process and the available evidence. It is most useful when clinical clarification is needed or when there is a question about how the criteria were applied. You can request it in the same letter as a written appeal, as a fallback, with the prescriber's availability stated.

A P2P request does not pause or extend the appeal deadline unless the plan confirms it does. File the written appeal on time.

Prepare the prescriber with:

  • The specific denial reason and the payer criteria that were cited
  • The person's complete clinical timeline in chronological order
  • Lab values, event dates and documented prior therapies and outcomes
  • A clear, one-sentence statement of what the technology will change clinically
P2P preparation tip

Approach the P2P with the applicable coverage criteria in hand. Lead with the clinical facts and let the data make the case. Precise, criteria-aligned documentation is more effective than an emotional appeal.

Expedited review

Expedited review may be available when the circumstances meet the payer's criteria for urgent handling. State the basis explicitly, such as an active medication titration that cannot be evaluated without the technology, a coverage lapse or the person's out-of-pocket costs while the appeal is pending.

The payer decides whether a request qualifies for expedited handling.

Optional AI help
AI promptPrepare a peer-to-peer briefingHelp me prepare a peer-to-peer review briefing for a prescriber. The PA for [technology] was denied by [payer name]...

Help me prepare a peer-to-peer review briefing for a prescriber. The PA for [technology] was denied by [payer name] for the following reason: [paste denial reason]. The payer's clinical policy requires: [paste criteria]. The patient's clinical history is: [paste relevant data]. Summarize the key clinical points the prescriber should lead with during the peer-to-peer call, organized chronologically. Focus on facts, lab values, event dates, and documented prior therapies and/or interventions and their outcomes.

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.

6Document everything

Log every submission, denial, appeal and P2P request with dates, outcomes and the name of any payer representative or medical reviewer involved. This creates a record for escalation if needed and builds knowledge of payer processes for future requests.

  • Keep proof of timely filing, such as a fax transmission confirmation, and retain the complete packet in the chart.
  • A pharmacy notification is the earliest signal of approval, not the formal determination. Obtain and file the payer's written decision.
Use the tracking recordStep 7 of Prepare and Follow UpReference number, owner, dates, decision and fulfillment, ready to copy into the EHR
See it applied

Case study: From denial to approval

A CGM denial where the person did not meet the plan's criterion, overturned on expedited written review within 72 hours by requesting a medical necessity exception.

Read the case study
← Prior Authorization overview

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