How to appeal a Humana continuous glucose monitors & insulin pumps denial

The framework that applies to your appeal

Medicare Advantage plans follow a separate appeal track from commercial plans. Reconsideration must be requested within 60 days; if the plan misses its deadline, the case auto-forwards to the IRE (Maximus).

Humana-specific note: Heavily Medicare Advantage focused. MA-specific appeal track (42 CFR Part 422 Subpart M) applies — 60 days to request reconsideration, NOT the 180 days for commercial plans. Auto-forward to IRE (Maximus) if Humana misses deadline.

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

Cited policy: Humana Medical Coverage Policy - CGM (MA follows LCD L33822)

MA: CMS LCD L33822. Commercial: similar.

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

Where Humana pushes back: 1) 'Beneficiary did not have an in-person visit within 6 months'; 2) 'No documented training on CGM use'; 3) 'Supply allowance exceeded' (A4239 refills).

Counter-arguments that hold up: Provide dated office visit note explicitly addressing CGM. Cite LCD L33822 in-person visit criteria are met. For MA denials of items covered by FFS Medicare: 42 CFR §422.101(b)(2) parity rule + cite the specific LCD provision.

What Humana typically denies for continuous glucose monitors & insulin pumps

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

• MA plan step therapy on Part B drugs
• Skilled nursing facility days
• Prior auth on specialty drugs
• OON emergency 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 Humana

1. Read the denial letter — note the exact denial reason code and the appeal deadline (60 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 Humana cited in the denial.
3. File the appeal through Humana's portal (members: https://www.humana.com ; providers: https://www.humana.com/provider). 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 KY, 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 Humana's prior-authorization criteria by drug: Humana PA criteria on ApprovalHelp.