Find policies, billing codes, payers, states, and providers
Diabetic Testing Supplies Prior Authorization Request Form
Customize your policy alerts
Sign up for all Aetna policy alerts
Know when Aetna releases new policies or updates existing guidance.
Monitor payer policy activity
Aetna prior authorization request form and process for diabetic blood glucose meters and test strips, including preferred products, clinical reasons for nonpreferred supplies, quantity limits, and documentation requirements; used by prescribers to request coverage for meters or test strips for Aetna members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Diabetic Testing Supplies
Nonpreferred supply authorization
Authorization for nonpreferred supplies is supported when ONE OR MORE of the following clinical reasons are documented on the prior authorization form and the prescriber completes required form fields:
Form asks whether the member has tried OneTouch Verio/Verio Flex/Verio IQ and requires an explanation if the LifeScan option is not usable or has been tried and failed.
No prior authorization is required for requests of up to three test strips per day.
The form asks providers to consider switching the member to a preferred LifeScan OneTouch product (for example, OneTouch Ultra/UltraMini or OneTouch Verio series). Requests for nonpreferred meters or test strips should include clinical justification; if a member cannot be switched, the form requires documentation of the specific clinical reason(s) why a preferred LifeScan product is not appropriate.
Coding and Quantity Limits
| Primary ICD code | Primary diagnosis ICD code (to be provided by prescriber on form) |
| Secondary ICD code | Secondary diagnosis ICD code (to be provided by prescriber on form) |
Provider Actions, Documentation, and Risks
Prior authorization required for nonpreferred meters/strips
Prior authorization is required to request coverage for a nonpreferred diabetic meter or test strips beyond the standard allowance; the form must indicate whether the request is for a meter or test strips, include the brand name, and specify supply quantity and days' supply requested. Note: up to three test strips per day do not require prior authorization.
- Indicate whether request is for a meter or test strips and provide brand name
- Provide quantity requested and days' supply
- Document how many times per day the member is testing and date of last in-person diabetes visit
Consider switching to preferred LifeScan OneTouch products
Providers are asked to consider switching members to one of the preferred LifeScan OneTouch products listed on the form and, if the member cannot be switched, to document the specific clinical reason(s) why (e.g., blindness requiring a talking meter, insulin pump interoperability, limited dexterity, low blood volume requirement, or other). The form asks whether the member has tried OneTouch Verio/Verio Flex and requests the medical reason if not usable or tried and failed.
- Consider switching to a preferred product (OneTouch Ultra/UltraMini, Verio, Verio IQ, Verio Flex)
- If not switching, select and document clinical reason(s) from the form and provide supporting explanation
- Indicate whether member has tried OneTouch Verio products and provide reasons if not tolerated or usable
Complete prior authorization form with required clinical and administrative details
Complete all required fields on the prior authorization form: member and prescriber information, indication whether request is for meter or test strips with brand name, primary/secondary ICD diagnosis code(s), testing frequency, quantity requested and days' supply, date of last in-person diabetes visit, and whether medical record documentation supports the requested testing frequency.
- Prescriber contact and identification information (name, specialty, NPI/DEA, address, phone, fax)
- Primary and secondary ICD diagnosis codes must be provided
- Document testing frequency, quantity and days' supply requested, date of last in-person visit, and whether supporting documentation exists in the medical record
Fraud risk for false or concealed information on request
Any person who knowingly files a request with materially false information or conceals material information to mislead the insurer may be committing a fraudulent insurance act and is subject to criminal and civil penalties; such actions risk denial and further legal consequences.
- Signature and date required on the form acknowledgement
- Providing materially false information or concealing material facts may result in criminal and civil penalties
Background
Home blood glucose monitoring relies on specific meters and corresponding test strips. To manage cost and clinical consistency, the payer maintains a list of preferred LifeScan products and expects members to be switched to these products when appropriate. The prior authorization form captures functional limitations (for example, blindness requiring a talking meter, visual impairment, limited dexterity, cognitive impairment), device-specific needs (such as a low volume meter < 0.4 µL blood volume), insulin pump interoperability, and whether the member has tried OneTouch Verio/Verio Flex. When a nonpreferred product is requested, the form requires the prescriber to document the clinical reason(s) for that request and to provide testing frequency, quantity and days' supply, date of last in-person diabetes visit, and whether supporting documentation is available in the medical record.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.