You Just Got Denied β Here's What to Do Right Now
Getting a denial letter for your continuous glucose monitor (CGM) sensors or diabetes supplies is frustrating, stressful, and frankly unfair. But here's what you need to know immediately: a denial is not the end. Insurance companies deny claims expecting most people to give up. You don't have to. This guide gives you the exact steps, language, and deadlines to fight back β and win.
Step 1: Understand Why You Were Denied (Read the Letter Carefully)
Your denial letter must legally state the reason for denial. Common reasons include:
- Not medically necessary β the insurer claims your doctor hasn't justified the need
- Step therapy required β the plan wants you to try a "preferred" alternative first
- Prior authorization not obtained β the claim was submitted without advance approval
- Non-formulary item β your specific CGM brand isn't on their approved drug/device list
- Frequency limits exceeded β you're requesting sensors more often than their policy allows
The reason matters because your appeal language must directly address it. Write down the exact denial code and reason before you call anyone.
Step 2: Call Your Insurer Immediately β Use This Script
Call the Member Services number on the back of your insurance card within 24β48 hours of receiving the denial. Ask for the Appeals and Grievances Department. Take notes and get the representative's name and ID number.
Phone Script:
"Hello, my name is [Your Name] and my member ID is [ID Number]. I received a denial for my continuous glucose monitor on [Date] under claim number [Claim #]. I am calling to formally initiate an internal appeal and to request a complete copy of my denial file, including the clinical criteria used to make this decision. I'd also like the name of the medical reviewer who issued this denial. Can you confirm the deadline for me to submit my written appeal?"
Federal law under the Affordable Care Act requires insurers to give you at least 180 days to file an internal appeal. However, many state deadlines are shorter β confirm yours on the call.
Step 3: File a Formal Internal Appeal β With This Letter
Submit your appeal in writing. Send via certified mail AND email if possible. Include your doctor's letter of medical necessity, your diabetes diagnosis documentation, and any peer-reviewed studies supporting CGM use.
Sample Appeal Letter:
[Your Name]
[Address]
[Date]
Appeals and Grievances Department
[Insurance Company Name]
[Address]
Re: Formal Internal Appeal β Claim Denial for Continuous Glucose Monitor
Member ID: [ID] | Claim #: [Claim Number] | Date of Denial: [Date]
Dear Appeals Review Committee,
I am writing to formally appeal the denial of coverage for my continuous glucose monitor (CGM) system, which was denied on [Date] under the reason of [stated denial reason]. I am a patient with [Type 1 / Type 2] diabetes under the care of Dr. [Name], and this device is medically necessary for the safe management of my condition.
The American Diabetes Association (ADA) Standards of Medical Care recommends CGM use for all individuals with diabetes on insulin therapy, as it significantly reduces hypoglycemic events and improves HbA1c outcomes. Denying this technology creates a documented patient safety risk.
Enclosed please find: (1) Letter of Medical Necessity from Dr. [Name], (2) My most recent lab results including HbA1c, (3) Documentation of prior hypoglycemic episodes, (4) Relevant peer-reviewed clinical studies.
I request an expedited review given the urgent medical nature of this appeal. Please confirm receipt and provide a decision within the federally required 30-day window for non-urgent internal appeals (or 72 hours for urgent/expedited appeals).
Sincerely,
[Your Name]
[Phone Number] | [Email]
Step 4: Request a Formulary Exception or Peer-to-Peer Review
If your denial is based on a non-formulary issue, ask your doctor to submit a formulary exception request β a formal process where your physician explains why the denied device is medically superior to covered alternatives. Additionally, your doctor can request a peer-to-peer review, a direct call with the insurance company's medical reviewer. This call alone reverses many denials.
Step 5: File an External Appeal If the Internal Appeal Fails
If your internal appeal is denied, federal law guarantees your right to an independent external review conducted by a third party β not your insurer. Request this in writing immediately after your internal denial. For Medicare patients, file through CMS (Centers for Medicare & Medicaid Services) at medicare.gov or call 1-800-MEDICARE. For commercial insurance, contact your State Insurance Commissioner β they can investigate bad-faith denials and have enforcement authority.
Step 6: File a Complaint in Parallel
Don't wait for appeals to conclude before filing a complaint with your State Insurance Commissioner's office. This creates a paper trail and often accelerates insurer action. Find your state's insurance department at naic.org/state_web_map.htm.
Get Supplies Now β While You Fight the Denial
Insurance battles take time β sometimes weeks. You still need sensors and supplies today. MDS Diabetes (mdsdiabetes.com) carries a full range of CGM sensors, lancets, test strips, and diabetes supplies that are FSA and HSA eligible β no prior authorization required, no insurance hoops. Use your FSA/HSA card directly at checkout and keep your diabetes management on track while your appeal moves forward.
Key Deadlines to Know
- Internal Appeal Deadline: 180 days from denial (ACA minimum)
- Urgent/Expedited Appeal Decision: 72 hours
- Standard Internal Appeal Decision: 30 days (pre-service) / 60 days (post-service)
- External Appeal Request: Typically within 4 months of internal denial
Do not let deadlines pass. Set calendar reminders the day you receive any denial or decision letter.