Letter of medical necessity: CGM

[PRESCRIBER LETTERHEAD]

[DATE]

[INSURER NAME]

Attn: Medical Review / Prior Authorization

Re: Letter of medical necessity for continuous glucose monitoring

Patient: [PATIENT NAME], DOB [DOB]

Member ID: [MEMBER ID]

Diagnosis: [ICD-10 CODE AND DESCRIPTION]

Device requested: [DEVICE NAME AND SUPPLY CODES]

To the medical reviewer,

I am the treating [endocrinologist / physician / advanced practice provider] for [PATIENT NAME], who has [type 1 diabetes / insulin-treated diabetes] diagnosed in [YEAR]. I am requesting coverage of continuous glucose monitoring.

Clinical background:

- Current regimen: [multiple daily injections / insulin pump], [NUMBER] injections or boluses per day.

- Most recent A1c: [VALUE] on [DATE]. Prior values: [VALUES AND DATES].

- Documented hypoglycemia: [NUMBER] episodes below 70 mg/dL in the past [PERIOD], including [NUMBER] below 54 mg/dL. [Note any episodes requiring assistance.]

- [If applicable:] The patient has impaired awareness of hypoglycemia.

- [If applicable:] The patient has had [NUMBER] emergency department visits or hospitalizations related to glycemic events since [DATE].

Medical necessity:

Continuous glucose monitoring is standard of care for insulin-treated diabetes and is recommended in current professional guidelines for patients on intensive insulin therapy. In this patient it is necessary to detect and prevent hypoglycemia that fingerstick testing cannot capture, particularly overnight, and to allow safe insulin dose adjustment.

Alternatives considered:

Fingerstick self-monitoring at [NUMBER] times per day has been insufficient because [SPECIFIC REASON: nocturnal events undetected, glycemic variability, hypoglycemia unawareness].

Without continuous glucose monitoring, this patient is at elevated risk of severe hypoglycemia and diabetic ketoacidosis, both of which carry a risk of hospitalization and death.

I am available at [PHONE] to discuss this case with the reviewing physician. I request a peer-to-peer review if this request is not approved.

Sincerely,

[PRESCRIBER NAME, CREDENTIALS]

NPI: [NPI]

[PRACTICE, PHONE, FAX]