Medicare Denied Her CGM: How Sarah Won Her Appeal
When Sarah Johnson, a 72-year-old Medicare beneficiary with Type 2 diabetes, received her medicare cgm denial letter, she felt devastated. After years of struggling with finger sticks, her doctor recommended a continuous glucose monitor (CGM) – but Medicare said no. However, Sarah Johnson’s medicare cgm denial appeal success is a story worth telling. Today, we’re sharing how Sarah successfully appealed her Medicare CGM denial, and the exact steps you can take if you’re facing a similar situation.
This article provides general information about Medicare CGM appeals and should not be considered medical advice. Always consult your healthcare provider and verify coverage with Medicare directly.
Understanding Sarah’s Medicare CGM Denial
Like many seniors, Sarah initially received a denial because her documentation didn’t fully meet Medicare’s requirements. Her doctor had prescribed a CGM, but the paperwork was missing key elements that Medicare needed to approve coverage.
Common Reasons for CGM Denial:
• Incomplete documentation of diabetes diagnosis
• Missing evidence of diabetes management training
• Insufficient proof of hypoglycemic events
• Lack of recent face-to-face visit documentation
• Incorrect coding on the claim
Sarah’s Story: From Denial to Approval
The Initial Setback
“I cried when I got that denial letter,” Sarah recalls. “My arthritis made finger sticks so painful, and I’d had two scary low blood sugar episodes. I thought Medicare would understand.”
Sarah’s denial letter stated: “Documentation insufficient to establish medical necessity.” Like many seniors, she didn’t know this was just the beginning, not the end.
The Turning Point
Sarah’s daughter found information about Medicare appeals online. “Mom, you have rights,” she said. “Let’s fight this together.”
Steps to Medicare CGM Denial Appeal Success
Sarah followed these crucial steps to overturn her denial:
1. Gathered Complete Medical Records
• Recent A1C test results
• Documentation of hypoglycemic events
• Records of diabetes education
• Previous 6 months of doctor visits
Sarah’s approach: “I created a binder with tabs for each type of document. Organization was key.”
2. Obtained Supporting Letter
• Detailed letter from endocrinologist
• Specific mention of Medicare coverage criteria
• Documentation of medical necessity
What made the difference: Her doctor’s revised letter specifically stated she had “two documented Level 2 hypoglycemic events requiring third-party assistance.”
3. Filed Level 1 Appeal (Redetermination)
• Submitted within 120 days of denial
• Included all supporting documentation
• Used Medicare’s official forms
💡 Pro Tip: Keep copies of everything you submit to Medicare. Sarah created a dedicated folder for all her appeal documentation.
Key Factors in Sarah’s Appeal Victory
Sarah’s medicare cgm denial appeal success hinged on three critical elements:
- Thorough documentation of two Level-2 hypoglycemic events
- Proof of completing CGM training
- Evidence of regular diabetes management visits
The Documentation That Won Sarah’s Case
Medical Records Included:
Emergency Room Visit #1 (March 2024)
- Blood glucose: 48 mg/dL
- Required glucagon injection
- Husband called 911
- Clear Level 2 hypoglycemia
Emergency Room Visit #2 (May 2024)
- Blood glucose: 52 mg/dL
- Confusion and inability to self-treat
- Neighbor assisted with glucose tablets
- Another Level 2 event documented
Doctor’s Letter Key Points:
“Mrs. Johnson experiences hypoglycemia unawareness due to her long-standing diabetes. She has documented Level 2 hypoglycemic events requiring third-party intervention. A CGM is medically necessary to prevent life-threatening episodes.”
Additional Supporting Evidence:
- Six months of blood sugar logs showing erratic patterns
- Pharmacy records proving insulin use
- Husband’s written statement about nighttime lows
- Recent diabetes education certificate
Timeline of Sarah’s Appeal Journey
Day 1: Received denial letter
Day 3: Called Medicare for clarification
Week 1: Scheduled appointment with doctor
Week 2: Gathered all medical records
Week 3: Doctor wrote detailed appeal letter
Week 4: Submitted Level 1 appeal
Week 8: Received approval!
“Those 8 weeks felt like forever,” Sarah admits, “but it was worth it.”
Working with Your Doctor for Appeal Success
Sarah’s Doctor Collaboration Tips:
Be Specific About Needs “I told my doctor exactly what Medicare denied and asked for help addressing each point.”
Provide Medicare’s Requirements “I brought Medicare’s CGM coverage criteria to my appointment.
Request Detailed Documentation “My doctor didn’t realize how specific the letter needed to be initially.”
What Your Doctor Should Include:
- Exact diagnosis codes (E11.649 for Type 2 with hypoglycemia)
- Specific hypoglycemic events with dates
- Clear statement of medical necessity
- Confirmation of face-to-face visits
- Your diabetes management plan
Common Pitfalls Sarah Avoided
❌ Mistakes That Can Delay Appeals:
- Waiting too long to file (120-day deadline)
- Sending incomplete documentation
- Not following up on submission
- Giving up after first denial
- Not keeping copies
✅ What Sarah Did Right:
- Filed appeal promptly (within 30 days)
- Over-documented rather than under-documented
- Followed up weekly
- Stayed persistent
- Kept meticulous records
The Appeal Letter That Made the Difference
Sarah’s appeal letter structure:
Opening: “I am appealing the denial of my CGM coverage dated [date], claim #[number].”
Medical History: Brief summary of diabetes diagnosis and complications
Specific Events: Detailed description of hypoglycemic episodes
Medical Necessity: How CGM would prevent future emergencies
Supporting Documents: List of all enclosed records
Closing: Request for reconsideration with contact information
After Approval: Sarah’s New Life with CGM
Immediate Benefits:
- No more painful finger sticks
- Peace of mind for nighttime lows
- Husband can monitor remotely
- Better overall glucose control
Sarah’s A1C Progress:
- Before CGM: 8.2%
- After 3 months: 7.1%
- After 6 months: 6.8%
“I wish I’d fought harder sooner,” Sarah reflects. “The CGM changed everything.”
Your Medicare CGM Appeal Checklist
Print and use this checklist:
☐ Denial letter with claim number
☐ Last 6 months of medical records
☐ Documentation of hypoglycemic events
☐ Current medication list
☐ Blood sugar logs (if available)
☐ Doctor’s support letter
☐ Completed appeal form
☐ Copies of everything
☐ Certified mail receipt
Expert Tips for Appeal Success
From Medicare Advocates:
“Be Persistent” “Most successful appeals happen at Level 1 or 2. Don’t give up.” – Joan M., SHIP Counselor
“Document Everything” “The more evidence, the better. Quality and quantity matter.” – Robert K., Medicare Specialist
“Get Help” “Free assistance is available through SHIP counselors.” – Maria S., Senior Advocate
From Successful Appellants:
Tom, 70: “I included photos of my bruised fingers from testing. Visual evidence helped.”
Betty, 68: “My daughter’s letter about finding me confused from low blood sugar made a difference.”
James, 73: “I highlighted key phrases in my medical records with sticky notes for reviewers.”
Resources That Helped Sarah
Free Assistance:
- SHIP (State Health Insurance Program): 1-800-MEDICARE
- Medicare Rights Center: 1-800-333-4114
- Area Agency on Aging: Local support
Online Resources:
- Medicare.gov appeal forms
- Sample appeal letters
- CGM coverage guidelines
Professional Help:
- Medicare advocates
- Elder law attorneys
- Diabetes educators
What If Your Appeal Is Denied?
Don’t stop at Level 1:
Level 2: Reconsideration
- Different reviewer
- 180 days to file
- Often successful
Level 3: ALJ Hearing
- Present case to judge
- 60 days to file
- 50% success rate
Sarah’s Backup Plan: “I was prepared to go to Level 2, but thankfully didn’t need to.”
Preventing Future Denials
Sarah’s Maintenance Strategy:
- Keep prescriptions updated annually
- Document all hypoglycemic events
- Maintain regular doctor visits
- Save all CGM data reports
- Build relationship with supplier
Words of Encouragement from Sarah
“If you’re facing a Medicare CGM denial, don’t lose hope. I’m 72 years old and not tech-savvy, but I won my appeal. You can too. The key is staying organized, getting help when needed, and not giving up. Your health is worth fighting for.”
Your Next Steps
If you’ve received a Medicare CGM denial:
- Don’t panic – You have 120 days to appeal
- Call the denial reason – Understand what’s missing
- Schedule with your doctor – Get supporting documentation
- Organize your records – Create your appeal packet
- Submit your appeal – Via certified mail
- Follow up – Stay engaged in the process
Need Help with Your Medicare CGM Appeal?
Our specialists understand the appeals process and can guide you through each step.
Call Now: 727-831-3729
Free consultation about Medicare CGM appeals and coverage requirements
