How to win a prior authorization appeal

First, identify the decision

Get the written denial. Find the reason, the clinical criteria used, the date, the appeal deadline, the claim or authorization number, and whether the decision concerns medical necessity, a benefit exclusion, step therapy, coding, network status, or missing records. Ask for the full criteria and the records the reviewer considered.

Many ACA-governed plans offer an internal appeal followed by independent external review. Some plans have more than one internal level, and Medicare, Medicaid, grandfathered, or self-funded plans can follow different procedures. Use the instructions in your denial notice.

An internal appeal generally has to be filed within 180 days of the denial. Plans generally decide pre-service internal appeals within 30 days and post-service appeals within 60 days. Urgent cases move faster, when delay could seriously jeopardize life, health, or recovery, internal and external review can proceed at the same time.

Build the packet

1. A one-page appeal cover sheet with the requested action

1. The denial notice

1. A letter of medical necessity

1. Relevant chart notes, labs, CGM reports, glucose logs, and prior treatment history

1. The plan's criteria with each requirement checked off

1. Peer-reviewed guidelines or product indications, only where they answer the denial

1. A signed authorization if someone else is appealing for the patient

What clinicians often forget

The note has to state the diagnosis, exact device or treatment, prior alternatives with dates and outcomes, and the consequence of delay. For a CGM, include insulin use or qualifying hypoglycemia history, training, visit documentation, and why fingersticks don't adequately address the patient's risk. For a pump, document current insulin regimen, glucose patterns, hypoglycemia or DKA risk, education, ability to use the system, and why the requested pump's features are clinically necessary.

CGM medical-necessity core:

> [Patient] has [type of diabetes] and uses insulin [frequency/method]. They have [documented hypoglycemia, impaired awareness, glycemic variability, pregnancy, pediatric risk, or other relevant factor]. The requested CGM will provide alerts and trend data needed to [specific clinical goal]. The patient/caregiver has been trained and will use the device as prescribed. Attached records document [criteria].

Pump medical-necessity core:

> Despite [current regimen and monitoring], [patient] has [documented problem]. The requested pump is needed for [specific dosing precision, automated insulin delivery, low-glucose suspend, tubeless delivery, accessibility, or integration], which the available alternative doesn't provide. Delay creates a risk of [specific harm].

Submit through a trackable channel, confirm receipt, and calendar the decision date. If denied again, request external review promptly.

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