Cgm Dexcom denied for missing prior authorization by UnitedHealthcare?

UnitedHealthcare'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 UnitedHealthcare Denied Your Dexcom CGM — Prior Authorization Required

UnitedHealthcare requires advance approval before it will cover a Dexcom continuous glucose monitor. If your device was dispensed or prescribed without that approval in place — or if an authorization was requested but the supporting documentation did not satisfy UHC's criteria — the claim is denied as "prior authorization required." This is one of the most common and most successfully appealed denial types, because the clinical need for CGM is typically well-documented in the medical record.

## Why This Denial Is Appealable

A prior-auth denial is not a final determination that CGM is not covered for you — it is a procedural gate. On appeal, you can submit the documentation that the authorization process required, and the reviewer must evaluate whether you meet the published clinical criteria. If you do meet those criteria, the denial should be reversed.

## Federal Appeal Framework

• Internal appeal: Under ACA §2719 and ERISA §503 (for employer-sponsored plans), you are entitled to a full-and-fair internal review. The deadline to file is printed on your denial letter — act promptly.
• External review: If UHC upholds the denial internally, request independent external review. This option is generally available for approximately four months following a final internal denial.
• Expedited review: Available when a standard timeline would jeopardize your health or ability to regain maximum function. Request this in writing simultaneously with your internal appeal if your situation is urgent.
• Retroactive authorization: If the device was already dispensed and used, ask your prescriber to submit a retroactive prior-authorization request with full clinical documentation alongside your appeal.

## Documentation to Gather

1. Diagnosis confirmation — recent chart notes with diabetes diagnosis, relevant lab history, and clinical context showing need for continuous monitoring. 2. Prescriber medical-necessity letter — a detailed letter explaining why CGM is necessary for your individual management, referencing UHC's published prior-authorization criteria point by point. 3. UHC prior-authorization criteria — download UHC's current published clinical coverage policy for CGM/Dexcom from the UHC provider portal or request it from customer service; confirm which criteria your prescriber must address. 4. Prior monitoring history — documentation of previous glucose monitoring methods, frequency, and outcomes demonstrating why CGM is the appropriate next step. 5. Clinical severity evidence — records of any hypoglycemic episodes, emergency visits, or glycemic instability that support medical necessity.

## Criteria-Mapping Structure

Your appeal letter should address every criterion in UHC's published prior-auth policy. Use this structure:

| UHC Prior-Auth Criterion | How Your Chart Satisfies It | |---|---| | Confirmed diabetes diagnosis | [Chart note date, provider, diagnosis code] | | Prescriber specialty requirement (if any) | [Prescriber name, specialty, NPI] | | Documentation of clinical need | [Relevant visit notes, dates] | | Any step/prior-treatment requirement | [Prior monitoring records with dates and outcomes] |

Attach this mapping to your appeal letter so there is no ambiguity about which criterion each document satisfies.