How to appeal an Aetna continuous glucose monitors & insulin pumps denial

The framework that applies to your appeal

Federal law gives you the right to a full and fair internal appeal, then an external review by an independent third party.

Aetna-specific note: Owned by CVS Health since 2018. CVS Caremark is the PBM. Aetna ASA administers self-funded ERISA plans. Meritain Health is Aetna's TPA brand.

What Aetna's policy requires for continuous glucose monitors & insulin pumps

Cited policy: Aetna Clinical Policy Bulletin - Home Glucose Monitors

rt-CGM medically necessary for T1DM and insulin-requiring T2DM meeting any of: A1c >=7%, severe hypoglycemia/unawareness, pregnancy, intensive insulin therapy.

How Aetna denies continuous glucose monitors & insulin pumps — and how to counter it

Where Aetna pushes back: 1) 'Diabetes not adequately documented as type 1 / insulin-requiring'; 2) 'No documentation of severe hypo or unawareness for non-insulin T2'; 3) 'Pump replacement: existing pump still under warranty'; 4) 'Closed-loop / AID experimental'.

Counter-arguments that hold up: Aetna CPB 0070 explicitly recognizes pregnancy and hypoglycemia unawareness — quote back. Cite Brown NEJM 2019 (Control-IQ, FDA Dec 2019) and Russell NEJM 2022 (iLet, FDA May 2023) establishing AID as standard of care, NOT experimental. ADA 2025 Standard 7 Class A; ATTD 2023 consensus (Phillip Endocrine Reviews 2023).

What Aetna typically denies for continuous glucose monitors & insulin pumps

Across Aetna's commercial and Medicare books, denials cluster around a small number of patterns. For continuous glucose monitors & insulin pumps, expect:

• UM-2575 medical necessity denials
• Prior auth absent
• Step therapy on specialty drugs
• Out-of-network ER reduction

Treatments most often denied in this category

These are the continuous glucose monitors & insulin pumps treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Dexcom G7
• Dexcom G6
• Libre 3 Plus
• Libre 2 Plus
• Eversense 365
• Tandem t:slim X2

How to submit the appeal to Aetna

1. Read the denial letter — note the exact denial reason code and the appeal deadline (180 days from the date on the letter).
2. Gather supporting documentation: physician letter of medical necessity, relevant clinical notes, peer-reviewed citations supporting the treatment for your indication, and the policy or coverage document Aetna cited in the denial.
3. File the appeal through Aetna's portal (members: https://www.aetna.com ; providers: https://www.aetnaprovider.com). Standard decision returns within 30 days; expedited urgent appeals return within 72 hours.
4. If denied again, request external review by an independent reviewer within 4 months of the final internal denial. In CT, the state insurance department coordinates external review for fully-insured plans; ERISA self-funded plans use a federal external review through DOL/EBSA.

Clinician or prior-auth team handling this on the practice side? See Aetna's prior-authorization criteria by drug: Aetna PA criteria on ApprovalHelp.