Prior Authorization Appeal

SAMPLE — not a real letter. Names, amounts, and account numbers are fictional.

May 11, 2026 Jordan Sample 123 Sample Street Anytown, ST 00000 Cascade Mutual Insurance Appeals Department P.O. Box 0002 Sampleville, ST 00002 RE: Appeal of prior authorization denial — Member ID MEM-0000-SAMPLE; Authorization request PA-0000-SAMPLE; continuous glucose monitor (HCPCS A4239 / E2103); denial dated May 4, 2026 Dear Appeals Department: I am appealing the denial of prior authorization for a continuous glucose monitor (CGM) requested by my endocrinologist, Dr. Alex Example. Your notice dated May 4, 2026 denies the request with the reason "does not meet plan clinical criteria; member has not documented four or more daily fingerstick tests." I ask that the denial be reversed and the authorization approved. I have type 1 diabetes, diagnosed in 2019, and I use multiple daily insulin injections. My records, enclosed, show two hypoglycemic events in the past 90 days: one on February 27, 2026 requiring assistance from a family member, and one on April 8, 2026 with a recorded glucose of 46 mg/dL. My most recent A1c, drawn April 15, 2026, was 8.4%. Dr. Example’s logs show an average of 3.7 fingerstick tests per day over the past 60 days, and her letter explains that the barrier to more frequent testing is the very pattern of nocturnal and unrecognized hypoglycemia the CGM is prescribed to address. The American Diabetes Association Standards of Care recommend CGM for people with type 1 diabetes on multiple daily injections regardless of fingerstick frequency, and specifically for patients with hypoglycemia unawareness or recurrent hypoglycemia. The denial applies a testing-count threshold to a patient whose documented problem is dangerous low blood sugar that testing has not caught. Because recurrent hypoglycemia is a safety issue, I request expedited review of this appeal. Dr. Example has confirmed in her enclosed letter that the standard review timeframe could seriously jeopardize my health. Please provide, with your determination, the specific clinical criteria applied and the name and specialty of the reviewing clinician. If this appeal is denied, I understand I have the right to an independent external review, and I intend to request it. Please send your determination in writing to the address above and to Dr. Example’s office. Sincerely, Jordan Sample Enclosures: Denial notice dated May 4, 2026; letter of medical necessity from Dr. Alex Example dated May 8, 2026; glucose logs, February–April 2026; lab report dated April 15, 2026