Cgm Dexcom denied for missing prior authorization by Humana?

Humana's specific coverage criteria for cgm dexcom are defined in its own published medical/coverage policy and the FDA-approved prescribing label. A successful appeal documents that your medical records satisfy each criterion those sources list — confirmed diagnosis, any required prior treatments (with dates and outcomes), and clinical severity. If the exact criteria weren't included with your denial, request them in writing; your appeal then maps each requirement to the matching fact in your chart.

## Why Humana Requires Prior Authorization for Dexcom CGM

Humana requires prior authorization (PA) for the Dexcom CGM system, meaning your provider must obtain advance approval before the claim will be covered. A denial stating "prior authorization required" generally means either that no PA was submitted before the device was dispensed, or that a PA was submitted but was denied for a substantive reason that is separately stated. The two situations require different responses: a missing PA may require a retrospective authorization request, while a denied PA requires a formal appeal.

## Why a PA Denial Is Appealable

Under ACA §2719, adverse PA determinations on non-grandfathered plans are subject to internal appeals and independent external review. ERISA §503 requires full-and-fair review for employer-sponsored plans. You have approximately 180 days from the denial notice to file your first internal appeal. External review must be requested within four months of the final internal denial. Expedited review (72-hour turnaround) is available when a delay poses a serious health risk — this is particularly relevant for CGM if you have documented hypoglycemia unawareness or significant glycemic instability.

## The Appeal Process

1. Confirm whether a PA was submitted. Contact your prescribing provider to verify. If no PA was submitted, ask whether a retrospective PA request is available under Humana's rules. 2. Obtain the PA denial rationale. Humana must state which clinical criteria were not met. 3. File a Level 1 internal appeal with a complete clinical package demonstrating that the criteria are met (see below). 4. File a Level 2 internal appeal if Level 1 is upheld. 5. Request external review after internal avenues are exhausted.

## Documentation to Gather

• Humana's PA criteria: Request the specific CGM prior-authorization criteria from Humana before drafting the appeal. Every argument should address a stated criterion.
• Diagnosis and monitoring history: Current diabetes diagnosis, type, duration, and treatment regimen including all current medications.
• Glycemic history: Chart documentation of fingerstick logs, HbA1c trends, hypoglycemic episodes, or emergency events related to glucose management.
• Prescriber PA letter: Your provider should address each of Humana's listed criteria directly, one by one, citing specific chart entries.
• FDA labeling: Attach to confirm the prescribed use is within the approved indication.

## Criteria-Mapping Structure

Obtain Humana's published prior-authorization criteria for CGM (request from Humana or your provider). Create a side-by-side table: Humana's criterion on the left, the specific clinical documentation that satisfies it on the right, with the date and source of each chart entry. This format directly answers the reviewer's checklist and is the most effective structure for overturning a PA denial.