Medicare CGM Prior Authorization: What UHC and Humana Patients Need to Know

Navigating Medicare CGM prior authorization for UnitedHealthcare (UHC) and Humana plans doesn’t have to be overwhelming. As a Medicare beneficiary managing diabetes, understanding how to get your Continuous Glucose Monitor (CGM) approved is essential for maintaining your health and peace of mind.

This article provides general Medicare information and should not be considered medical advice. Always consult your healthcare provider and insurance plan for personal medical decisions.

Understanding Medicare CGM Prior Authorization Basics

Prior authorization means getting approval from your Medicare Advantage plan before they’ll cover your CGM. Both UnitedHealthcare and Humana require this step to ensure the device is medically necessary for your diabetes management.

📌 Key Point: Prior authorization is not a denial – it’s simply a required step to confirm you meet Medicare’s coverage criteria.

Do You Qualify for CGM Coverage?

Medicare has specific requirements for CGM coverage in 2025:

• Diagnosed with Type 1 or Type 2 diabetes
• Regular visits with your healthcare provider (at least every 6 months)
• Either using insulin OR having documented problematic hypoglycemia
• Ability to use the CGM system safely (you or your caregiver)

Good News: As of 2025, Medicare no longer requires testing blood sugar 3 times daily to qualify for CGM coverage.

Step-by-Step Prior Authorization Process

For UnitedHealthcare Medicare Advantage Members:

1. Visit your doctor to confirm you meet Medicare’s CGM criteria
2. Your doctor submits the prior authorization request to UHC
3. Include recent medical records showing diabetes management
4. UHC typically responds within 14 calendar days

For Humana Medicare Advantage Members:

1. Confirm your plan requires prior authorization (not all do)
2. Your doctor submits clinical documentation to Humana
3. Expect a response within 72 hours for urgent requests
4. Standard requests typically process within 14 days

Real Member Experiences

Margaret’s UHC Success Story

Margaret, 73: “I was worried about the prior authorization, but my doctor’s office handled everything. They knew exactly what UHC needed. I had approval in 10 days and my FreeStyle Libre arrived the next week!”

What Made It Work:

• Doctor included 6 months of visit notes
• Documented her insulin use clearly
• Mentioned her arthritis making fingersticks difficult

Robert’s Humana Journey

Robert, 69: “Humana initially requested more information. My doctor sent my A1C history and a note about my overnight low blood sugars. Approved on the second try!”

Key Learning:

• Don’t panic if asked for more information
• Additional documentation is common
• Most requests are eventually approved

Critical Documentation Your Plan Needs

Both UHC and Humana Require:

✓ Diabetes diagnosis (ICD-10 codes)
✓ Recent office visit notes (within 6 months)
✓ Current medication list
✓ Blood glucose logs or A1C results
✓ Treatment plan from your doctor

Additional Helpful Documentation:

• History of hypoglycemic events
• Emergency room visits for low blood sugar
• Physical limitations affecting testing
• Previous CGM use (if applicable)

UnitedHealthcare Specific Requirements

UHC’s Unique Process:

Online Portal Benefits:

• Track authorization status
• Upload additional documents
• See approval letters
• Check which DME suppliers are approved

Contact Information:

• Prior Auth Phone: 1-866-604-3267
• Hours: Monday-Friday, 8 AM – 8 PM ET
• Online: myuhcmedicare.com

UHC Coverage Details:

• FreeStyle Libre: Covered, preferred
• Dexcom G6/G7: Covered with documentation
• Approval Duration: 12 months typically
• Renewal: Required annually

Humana Specific Requirements

Humana’s Streamlined Approach:

CenterWell Pharmacy Option:

• Integrated with Humana
• Often faster approvals
• Direct billing to Humana
• Mail-order convenience

Contact Information:

• Prior Auth: 1-800-555-2546
• Pharmacy: 1-855-873-8739
• Hours: 24/7 for urgent requests

Humana Coverage Details:

• Preferred CGMs: Both FreeStyle Libre and Dexcom
• Copays: Vary by plan ($0-$47 typical)
• Auto-renewal: Available after first approval
• 90-day supplies: Mail-order option

Common Prior Authorization Challenges

Issue 1: “More Information Needed”

What This Means:

• Not a denial
• Missing specific documentation
• Common occurrence (40% of requests)

Your Action Plan:

1. Call your plan for specifics
2. Contact doctor immediately
3. Submit within timeframe given
4. Keep copies of everything

Issue 2: Timing Delays

Dorothy’s Tip: “I learned to request authorization 30 days before needing supplies. This gives time for any hiccups.”

Avoid Delays By:

• Starting early
• Following up weekly
• Having doctor mark “urgent” if needed
• Using in-network suppliers

Issue 3: Coordination Problems

Between doctor and insurance:

• Ensure correct fax numbers
• Confirm receipt of documents
• Get reference numbers
• Document all calls

Your Appeal Rights

If Prior Authorization is Denied:

Level 1: Reconsideration

• Request within 60 days
• Plan must respond in 72 hours (expedited)
• Include new documentation
• Success rate: ~30%

Level 2: Independent Review

• External review organization
• More formal process
• Often successful with proper documentation
• Consider getting help

Tips from Successful Members

Susan’s UHC Strategy:

“I created a ‘diabetes binder’ with all my records. When they needed information, I had it ready. Faxed everything the same day.”

James’s Humana Hack:

“I call every 3 days for updates. Being friendly but persistent keeps things moving. The representatives appreciate patience.”

Betty’s Universal Tip:

“Get your doctor’s prior auth specialist involved early. They do this daily and know exactly what insurers want.”

Documentation Checklist

Print and use this checklist:

For Your Doctor: ☐ Current medication list
☐ Recent visit notes
☐ Diagnosis codes
☐ Medical necessity letter
☐ Hypoglycemia documentation

For You to Provide: ☐ Insurance cards
☐ Contact information
☐ Preferred DME supplier
☐ Pharmacy information
☐ Emergency contact

Renewal Process

Planning Ahead:

90 Days Before Expiration:

• Schedule doctor appointment
• Gather recent glucose data
• Note any changes

60 Days Before:

• Doctor submits renewal
• Confirm with insurance
• Don’t wait for reminders

30 Days Before:

• Follow up if no response
• Ensure continuous coverage
• Order supplies early

Cost Considerations

UnitedHealthcare Costs:

Typical Copays:

• HMO Plans: $35-47/month
• PPO Plans: $40-60/month
• Some plans: $0 with preferred suppliers

Humana Costs:

Cost Structure:

• Basic plans: 20% coinsurance
• Enhanced plans: Fixed copays
• CenterWell Pharmacy: Often lower
• Mail order: 90-day savings

Preferred Supplier Networks

Why It Matters:

In-Network Benefits:

• Lower costs
• Easier authorization
• Direct billing
• Better coordination

Finding Preferred Suppliers:

1. Check plan website
2. Call member services
3. Ask during prior auth
4. Verify before ordering

Emergency Situations

If You Need CGM Immediately:

For UHC:

• Request expedited review
• Must respond in 72 hours
• Doctor notes urgency
• Provide clinical justification

For Humana:

• 24-hour review available
• Call clinical team directly
• Temporary override possible
• Bridge supplies available

Technology Tips

Using Plan Apps:

UHC App Features:

• Upload documents
• Check status
• Message center
• Find suppliers

Humana Go365:

• Track authorizations
• Earn rewards
• Health reminders
• Document storage

Success Strategies Summary

Before Starting:

1. Verify plan requirements
2. Gather all documentation
3. Choose in-network supplier
4. Schedule doctor visit

During Process:

1. Submit complete information
2. Follow up regularly
3. Document everything
4. Stay patient but persistent

After Approval:

1. Understand coverage duration
2. Mark renewal dates
3. Keep approval letters
4. Plan ahead

Key Takeaways

✓ Prior authorization is normal, not personal
✓ Complete documentation speeds approval
✓ Both UHC and Humana want to help
✓ Persistence pays off
✓ Start early to avoid gaps

Your Next Steps

1. Call your plan to understand specific requirements
2. Schedule doctor visit if needed
3. Gather documentation using our checklist
4. Choose supplier from preferred network
5. Start process 30+ days before needing supplies

Remember: Most prior authorizations are approved. The key is providing complete information and following up appropriately.

Need Help with Medicare CGM Prior Authorization?

Our specialists understand UHC and Humana requirements and can guide you through the process.

Call Now: 727-831-3729

Free consultation about Medicare CGM prior authorization