Letter of medical necessity: insulin pump

[PRESCRIBER LETTERHEAD]

[DATE]

[INSURER NAME]

Attn: Medical Review / Durable Medical Equipment

Re: Letter of medical necessity for insulin pump therapy

Patient: [PATIENT NAME], DOB [DOB]

Member ID: [MEMBER ID]

Diagnosis: [ICD-10 CODE AND DESCRIPTION]

Device requested: [PUMP MODEL AND CODES]

Request type: [new start / warranty replacement]

To the medical reviewer,

I am requesting coverage of insulin pump therapy for [PATIENT NAME], who has [type 1 diabetes / insulin-requiring diabetes] diagnosed in [YEAR].

Clinical justification:

- Current regimen: [DESCRIBE], with [NUMBER] insulin injections daily.

- Most recent A1c: [VALUE] on [DATE].

- The patient self-monitors [NUMBER] times daily by fingerstick and/or uses [CGM DEVICE].

- Glycemic pattern shows [dawn phenomenon / wide variability / recurrent nocturnal hypoglycemia / postprandial excursions], documented in the enclosed logs from [DATE RANGE].

- [If applicable:] [NUMBER] episodes of severe hypoglycemia requiring assistance since [DATE].

- [If applicable:] [NUMBER] episodes of diabetic ketoacidosis since [DATE].

Why multiple daily injections are insufficient:

[Two or three sentences specific to this patient.]

Pump therapy, particularly automated insulin delivery, allows continuous basal adjustment that injection therapy cannot replicate. In this patient it is necessary to reduce hypoglycemia risk and improve time in range.

The patient has demonstrated the ability to manage this therapy: [describe adherence, carb counting competence, engagement with the care team, completed pump training].

[If replacement:] The patient's current pump, serial [NUMBER], is out of warranty as of [DATE] and [is malfunctioning / no longer supported].

I request approval and am available for peer-to-peer review at [PHONE].

Sincerely,

[PRESCRIBER NAME, CREDENTIALS]

NPI: [NPI]

[PRACTICE, PHONE, FAX]

Enclosures: glucose logs or CGM report, chart notes, prior therapy documentation