Prior Authorization Request (Advanced Imaging)

Date of Request: [Date]

Request Type: [Initial / Resubmission / Appeal / Peer-to-peer requested]

Urgency: [Routine / Expedited] (If expedited, justify in the Medical Necessity Synopsis with specific risk of harm from delay.)

Patient: [Full name], [DOB], [MRN]

Insurance: [Plan name], [Member ID], [Group number]

Facility/Site of Service: [Facility name and address or NPI]

Ordering Clinician: [Name, credentials, specialty]

NPI: [Ordering clinician NPI]

Contact for Peer-to-Peer: [Phone], [Fax], [Best call times]

Requested Study

Modality: [MRI / CT / Ultrasound]

Protocol: [Anatomic region], [Laterality], [With contrast / Without contrast / With and without contrast], [Contrast type if known]

CPT Code(s): [CPT codes]

ICD-10 Code(s): [Primary diagnosis and symptom codes]

Clinical Question: [One sentence stating the target diagnosis to confirm or exclude and the clinical rationale] (Be specific about pathology and context; avoid generic statements.)

Medical Necessity Synopsis

[4–8 sentence narrative synthesizing the case for approval] (Include: chief complaint with onset, duration, and trajectory; key objective findings or explicit failure of conservative therapy with functional impairment; relevant prior testing and why inadequate; why this modality is needed now; and how results will change management. Embed specific dates, durations, and exam findings. Write as a single paragraph suitable for standalone review.)

Clinical History and Examination

Chief Complaint: [Primary symptom(s), location, laterality, distribution]

Timeline: [Onset date], [Course: improving / stable / worsening / recurrent], [Severity: pain score or equivalent], [Functional impact], [Night pain or episode frequency]

Relevant Medical History: [Problem-focused history affecting appropriateness, urgency, safety, or protocol] (Include prior surgery to region, malignancy history, infection risks, CKD, pregnancy status, implanted devices, or other factors influencing modality/contrast choice.)

Physical Examination: [Objective findings pertinent to region] (For spine/neurologic: motor strength by myotome, reflexes, dermatomal sensation, gait, straight-leg raise, bowel/bladder findings. For MSK: ROM, swelling, instability tests, tenderness. For abdominal/pelvic: localized tenderness, guarding, palpable mass. If exam not performed, state reason and reference other objective data with source and date.)

Pertinent Negatives: [Negatives relevant to approval criteria] (Document explicitly, e.g., absence of fever for infection concern, absence of bowel/bladder dysfunction for cauda equina.)

Conservative Management and Prior Evaluation

Non-Pharmacologic Therapy: [Physical therapy: supervised vs home, dates, visits, adherence], [Activity modification], [Bracing/orthotics], [Other therapies], [Response: improved / no change / worsened]

Pharmacologic Therapy: [NSAIDs/acetaminophen: duration and response], [Neuropathic agents], [Muscle relaxants], [Oral steroids], [Contraindications or intolerance] (Include start/stop dates and outcomes.)

Procedures/Specialist Care: [Injections], [Prior surgery], [Specialist evaluations], [ED visits] (Include dates and degree/duration of relief.)

Prior Imaging/Testing: [Modality, body part, date, key result] (State why insufficient: wrong region, too early, non-diagnostic, or does not address current question. If repeating imaging, specify clinical change prompting repeat.)

Summary Statement: [Explicit statement of persistence despite therapy] (Example: "Persistent symptoms despite [X weeks] of [specific therapy], resulting in [functional limitation].") (Avoid generic phrases without specifics.)

Red Flags

• [ ] Suspected malignancy (history of cancer, unexplained weight loss): [Details with dates if present]
• [ ] Suspected infection (fever, immunosuppression, IVDU, recent bacteremia): [Details if present]
• [ ] Significant trauma or fracture risk (trauma, osteoporosis, chronic steroids): [Details if present]
• [ ] Progressive or severe neurologic deficit: [Distribution, strength/reflex changes, dates if present]
• [ ] Suspected cauda equina (urinary retention, saddle anesthesia, severe bilateral symptoms): [Details if present]
• [ ] Severe unremitting night pain or pain at rest: [Details if present]
• [ ] Other urgent/emergent indication: [Specify]

(If expedited, state why delay risks harm and what time-sensitive decision depends on imaging.)

Why This Modality

[Rationale for requested modality and protocol] (Justify based on diagnostic performance: MRI for soft tissue/neural detail and marrow/infection/neoplasm; CT for fracture/bony detail or acute hemorrhage; Ultrasound for vascular/soft tissue and dynamic assessment. State why alternatives are inadequate and why timing is appropriate now.)

How Results Will Change Management

• If [positive finding] → [Specific action: surgical referral, procedural planning, targeted therapy, oncologic workup]
• If [negative/benign finding] → [Alternative plan: continue conservative management, avoid invasive intervention, surveillance]
• If [concerning incidental finding] → [Expedited workup or referral]

Contrast and Safety Considerations

(Omit this section entirely for non-contrast ultrasound or when clearly not applicable.)

Contrast Justification: [Clinical reason contrast is needed; why non-contrast is insufficient] (Mark "Not applicable" for non-contrast studies.)

Contrast Risk Screening: [Prior contrast reaction and severity], [Premedication plan if applicable], [Most recent creatinine/eGFR with date], [Pregnancy/lactation considerations]

MRI Safety: [Implants/devices and MRI-conditional status], [Claustrophobia/sedation needs], [Body habitus limitations] (If unknown, document "unknown—will confirm prior to scheduling.")

Supporting Documentation

• [ ] Recent office visit note
• [ ] PT evaluation/progress notes
• [ ] Prior imaging reports
• [ ] Specialist consult notes
• [ ] Relevant labs
• [ ] Other: [Specify]

Attestation

I am the treating clinician for this patient's relevant medical problem. The imaging results will be used in clinical management. The information above is accurate and based on the current medical record.

Signature: [Name, credentials]

Date/Time: [Date and time]