By Amy Killelea and Christine Monahan
Prior authorization reform continues to be a top health care priority in state legislatures as states work through the 2026 legislative session. State actions have been driven by growing frustration from patients and providers alike who argue that arbitrary prior authorization policies are getting in the way of access to clinically appropriate care and treatment. Insurers, on the other hand, argue that utilization management—a range of techniques, including prior authorization, designed to ensure patients are receiving appropriate care—are necessary to reduce unnecessary care and to control costs.
Which view is correct? The answer is likely a mix of both. Utilization management can help ensure that services covered by a health plan are safe and effective for the individual patient and can incentivize use of the most cost-effective options. However, a growing body of evidence points to prior authorization policies getting this calculus wrong, resulting in denials of coverage that are in fact medically necessary.
A recent report published by Georgetown University McCourt School of Public Policy’s Center on Health Insurance Reforms (CHIR) adds to this evidence, using continuous glucose monitors (CGMs) as a case study. CHIR’s analysis found wide variability in coverage of CGMs across fully insured plans and many examples of plan coverage criteria that do not align with widely accepted clinical standards of care for diabetes. These findings could help inform efforts to put guardrails on prior authorization across a broad range of conditions and services to ensure it is not used to deny access to clinically appropriate care.
The Fine Print Of Plan Coverage Criteria
CHIR’s analysis focused on coverage policies for CGMs, devices that allow individuals to monitor their blood glucose levels every few minutes. CGMs make it easier for people with diabetes to monitor glucose levels, adjust insulin, and prevent dangerous complications from drops in blood sugar. Our analysis looked at whether CGMs are subjected to prior authorization (most are), and the clinical criteria that plans require patients to meet to get access to CGMs writ large or to specific CGM device types. These criteria are often buried within a plan’s medical necessity or utilization management policy documents, separate from plan formulary documents that often include only whether a CGM is covered and not the fine print detailing the specific requirements for coverage. However, these hard-to-find coverage criteria include critical information for patients and providers on whether a plan will cover a specific CGM based on the patient’s individual need.
CGM coverage presents an interesting case study to assess whether prior authorization policies are aligned with evidence-based standards of care. Unlike other services where there may not be a definitive evidence base demonstrating safety, efficacy, and clinical consensus, the American Diabetes Association (ADA) Standards of Care includes a robust review of recent evidence for CGMs, and based on this review strongly recommends early access to CGMs for people with insulin-requiring diabetes. Yet, for privately insured individuals, access to CGMs remains uneven, likely in part due to plan coverage barriers. CHIR’s report found widespread use of prior authorization for most covered CGMs as well as clinical criteria for CGM coverage that are not aligned with contemporaneous ADA recommendations.
These discrepancies between a plan’s coverage criteria and evidence-based clinical standards of care can have profound implications for access to care for patients. For example, requiring someone with insulin-requiring diabetes to demonstrate instances of blood glucose highs and lows before allowing that patient to access the CGM that might have prevented those dangerous swings in the first place presents a frustrating and risky catch-22. Similarly, using different clinical criteria for different device types when there are no clinical differences across CGM types that would justify differing criteria is confusing for patients and providers; it also suggests arbitrary policies that may be more focused on cost control than clinical outcomes.
Studies have identified this disconnect between plan prior authorization policies and up-to-date evidence-based standards of care for other conditions outside of diabetes. A recent report from mental and behavioral health experts, for example, found that plan utilization management and medical necessity policies often failed to provide access to generally accepted standards of care for mental health and behavioral health conditions, potentially running afoul of state and federal mental and behavioral health coverage laws. Another study analyzing prescription drug coverage policies found “weak alignment” between plan coverage policies and published clinical guidelines for particular medications; plan policies often imposed additional limitations on prescription drug coverage not recommended by clinical guidelines.
Cost Considerations On Both Sides Of Prior Authorization
Payers may argue that the limitations they place on use are necessary to keep costs down, especially in areas where there are multiple therapies available that may have similar safety and efficacy profiles but different negotiated prices. And while there is some logic to this point, researchers and economists are quick to point out that there are two sides to the cost ledger. Yes, new medications and devices often come with high price tags that insurance plans pass on to consumers in the form of higher premiums, but failing to effectively manage a chronic condition also comes with a price tag because of higher health care use. Early access to CGMs, for example, can reduce emergency department and hospitalization costs for patients with diabetes.
The price of inadequate access to necessary care and treatment is often a lot harder to quantify and may play out over a time horizon that doesn’t match the average time consumers spend on a private insurance plan. However, it’s an important consideration as payers and policy makers weigh the cost implications of prior authorization reforms.
How Are Policy Makers Reforming Prior Authorization To Ensure Patients Have Access To Clinically Recommended Care?
We have previously characterized prior authorization reform as falling into two categories. The first category includes process reforms that seek to ease the administrative burden of prior authorization, including reforms that speed up plan coverage decision timelines, create uniform prior authorization operational policies, and ensure prior authorization information is more transparently available to patients and providers. Transparency requirements would go a long way to help patients and providers better understand both what limitations plans place on particular services and the criteria patients must meet for certain services to be covered. As CHIR’s research found, information on CGM coverage policies was often difficult to find, confusing, or incomplete.
The second category includes more substantive reforms to prior authorization criteria that aim to more closely tether prior authorization to clinical standards of care. Pursuing substantive reforms is more directly relevant to addressing the disconnect between plan coverage policies and access to clinically appropriate care. Substantive prior authorization reforms have included requiring plans to cite peer-reviewed evidence to justify prior authorization decisions (for example, Alaska), prohibiting prior authorization for certain interventions where the evidence base indicates significant benefits from access and harms from delays or inappropriate denials (for example, Colorado and Nebraska), and requiring prior authorization appeals to be reviewed by a provider with requisite expertise in the clinical area at issue (for example, Delaware).
Prior authorization has emerged as a legislative priority over the past several years, and states are continuing to grapple with how to reform prior authorization in their 2026 sessions. To be sure, there are no easy solutions. As health care costs continue to rise—particularly for prescription drugs—prior authorization is an important cost containment mechanism that many policy makers are loathe to eliminate completely. However, they may be able to find middle ground in policies that put in place guardrails for prior authorization use to ensure patients still have access to clinically recommended care and treatment.
Christine H. Monahan and Amy Killelea “Continuous Glucose Monitor Coverage Criteria And The Need For Prior Authorization Reform” May 7, 2026, https://www.healthaffairs.org/content/forefront/continuous-glucose-monitor-coverage-criteria-and-need-prior-authorization-reform. Copyright © 2026 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.
