Cgm Dexcom denied for failing step therapy 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 Applies Step Therapy to Dexcom CGM

Humana's step-therapy (also called "fail-first") requirements for CGM may require that a patient first use a less costly or preferred monitoring approach before the Dexcom system is covered. A step-therapy denial means the insurer's records do not show documented use of — or a documented clinical reason to bypass — the required prior step. This is among the most overturnable denial types when your provider has already tried the required step, or when your clinical situation makes bypassing the step medically appropriate.

## Why This Denial Is Appealable

A growing number of states have enacted step-therapy reform laws that require insurers to grant exceptions when a required prior step has already failed, is contraindicated, or when a delay would cause harm. Even in states without specific step-therapy laws, ACA §2719 and ERISA §503 provide the standard internal-appeal and external-review framework. You have approximately 180 days from the denial to begin your internal appeal and approximately four months from the final internal denial to request external review. Expedited review is available when your health could be seriously harmed by delay.

## The Appeal Process

1. Identify Humana's required step. Request the specific step-therapy criteria in writing — what monitoring approach must be tried first, and for how long. 2. Document prior use or clinical exception. Determine whether the required step was already tried and failed, and when. 3. File a step-therapy exception request and a Level 1 internal appeal simultaneously. 4. File a Level 2 internal appeal if Level 1 is upheld. 5. Request external review after internal avenues are exhausted.

## Documentation to Gather

• Prior monitoring history: Dates, duration, and documented outcomes for any CGM or monitoring approach previously used, including any adverse outcomes, device failures, or clinical reasons for discontinuation.
• Prescriber step-therapy exception letter: Your physician should address each of Humana's step criteria directly, explaining either (a) that the required step was completed with documented outcomes, or (b) the clinical reason bypassing the step is medically necessary for this patient.
• Clinical severity documentation: Chart notes documenting glycemic instability, hypoglycemia unawareness, or other clinical features that support the exception.
• Applicable professional society guidance: Your prescriber may reference the relevant guideline organization (e.g., ADA Standards of Medical Care) generically to support the medical-necessity framing, without citing specific numeric criteria.

## Criteria-Mapping Structure

Request Humana's step-therapy exception criteria. Build a table matching each Humana criterion to the specific chart documentation that satisfies it — dates, provider names, findings, and outcomes. If the required prior step was attempted, document the start date, end date, and clinical reason for transition. A well-mapped appeal leaves no criterion unanswered.