Prior Authorization Request for Infusion Pump for Insulin

Blue KC will provide coverage for an external insulin pump when it is determined to be medically necessary.

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Enter Patient Information

  • Review Type:
  • Patient First Name: *
  • Patient Middle Initial:
  • Patient Last Name: *
  • Date of Birth: *
  • Patient Group ID: *
  • IDC-10 Diagnosis Codes: *
  • Diagnosis Codes must be 3-8 characters with NO decimals
    Codes must be 3 - 8 characters and no decimals.
  • CPT or HCPCS Codes: *
    (Include modifiers if applicable)
  • CPT/HCPCS codes must contain 5-9 charactersUnits may contain up to 3 characters
    Units:
  • Date of Service/Admission Date: *

* Required Field

Enter Provider Information

  • Contact First Name: *
  • Contact Last Name: *
  • Contact Email Address:
  • Contact Phone No:*
  • Contact Phone Ext:
  • Contact Fax No:*
  • Provider ID OR NPI: *
  •  
    • I am an Ordering Physician
    • I am a Servicing Physician
  • Ordering Physician's Name:
  • Ordering Physician's Address:
  • Ordering Physician's City:
  • Ordering Physician's State:
  • Ordering Physician's Zip:
  • Ordering Physician's Email Address:
  • Ordering Physician's Phone No:
  • Ordering Physician's Fax No:
  • Servicing Physician's Name:
  • Servicing Physician's Address:
  • Servicing Physician's City:
  • Servicing Physician's State:
  • Servicing Physician's Zip:
  • Servicing Physician's Email Address:
  • Servicing Physician's Phone No:
  • Servicing Physician's Fax No:
  • Facility/Supplier Name: *
  • Facility NPI:
  • Facility/Supplier Address: *
  • Facility/Supplier City: *
  • Facility/Supplier State: *
  • Facility/Supplier Zip: *

History of condition (including duration of condition, previous failed conservative treatments, etc.): *

Please complete the following:

  • Has the patient completed a comprehensive diabetes education program? Yes No
  • How many injections of insulin is the patient administrating per day?For how long?
  • Does the patient make frequent self-adjustments of the insulin dose? Yes No
  • How many times per day does the patient self-test?For how long?

While on the multiple daily injection regimen…

  • What is the patient's latest HbA1C?When was it last measured?
  • Does the patient have recurring hypoglycemia? Yes No
  • How often does the patient have recurring hypoglycemia?
  • Please give examples of glucose readings during those hypoglycemic events:
  • Does the patient have wide fluctuations in blood glucose before mealtime (>140)? Yes No
  • Does the patient have dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl? Yes No
  • Does the patient have a history of severe glycemic excursions? Yes No

Please attach relevant clinical documentation (Include blood glucose logs for the past two months): *

Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







  • Checking this box will send a copy of your form to the email address provided.

If you experience issues submitting this form, please print and fax it to (816) 817-8211.

If you have questions, contact Blue KC at (816) 395-3989.

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Member Prefix

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.

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