Prior Authorization Request (Advanced Imaging)

Prior Authorization Request: Advanced Imaging (MRI, CT, CTA, MRA)

(Request-first structure. Use absolute dates throughout. For required elements, use "unknown" or "not documented" if missing. Omit optional elements entirely if not applicable. Label non-current sources, e.g., "Per outside record dated [date]".)

Patient Name: [Patient full name] DOB: [Date of birth] Member ID: [Member ID] Group ID: [Group ID] (Only include if available)

Ordering Clinician: [Clinician name], [Credentials], NPI: [NPI], Practice: [Practice name]

Contact: [Phone] | [Fax]

Rendering Facility: [Facility name] (Only include if known)

Date of Request: [Date] Request Type: [initial / re-review / appeal / peer-to-peer follow-up]

Urgency: [routine / expedited] (If expedited, state clinical reason)

Requested Study

Modality: [MRI / CT / CTA / MRA]

Anatomy: [Body region, specific structure or level(s), laterality]

Contrast: [without / with / with-and-without] (If contrast requested, briefly justify why contrast is needed for the clinical question)

CPT Code(s): [CPT code(s)] (Include if required by payer)

Diagnosis: [Primary diagnosis] (ICD-10: [Code]) (ICD code optional unless payer requires)

Prior Auth Number: [Number] (Only include if already assigned)

Special Performance Needs: [Sedation / anesthesia support / bariatric scanner / other special need] (Only include if applicable)

Clinical Indication

[Problem statement capturing symptom complex, target anatomy, and why imaging is requested now]

• Onset and Duration: [Onset date or estimate; total duration]
• Precipitating Event: [Mechanism or event if relevant] (Omit if not applicable)
• Symptom Course: [improving / worsening / stable / recent change] [Brief description]
• Severity and Functional Impact: [Severity description; impact on ADLs, work, or neurologic function]
• Decision-Critical Red Flags: [Red flags present or absent that are relevant to the body region] (Only include red flags that map to utilization management criteria)
• Relevant Medical History: [Prior surgery in region / cancer history / immunosuppression / inflammatory disease / known degeneration] (Only include if it changes pretest probability)

Focused Physical Exam

• [Pertinent positive findings with quantification: strength grades, ROM in degrees, sensory distribution, reflexes, provocative maneuvers with results, gait assessment]
• [Decision-critical negatives relevant to the clinical question]

(If exam limited or unavailable, document reason and include objective data from documented sources with explicit source and date attribution. Do not include findings not documented in the record.)

Prior Workup and Treatment

Prior Imaging: (Include studies relevant to the current indication)

• [Modality], [Region], [Date], [Facility]: [Key one-line result]. Why insufficient: [Nondiagnostic / does not visualize suspected structure / interval change suspected / new symptoms since study]

Other Relevant Tests: (Only include if materially supportive of the indication)

• [Test type], [Date]: [Key result and relevance to current clinical question]

Conservative Treatment History: (Use absolute dates; document adherence and response; avoid conclusory phrases like "failed conservative therapy" without specifics)

• [Treatment type]: [Date range], [Adherence], [Response/outcome]

(If conservative therapy is absent or shorter than typical, document the clinical reason: objective neurologic deficit, suspected fracture/infection/malignancy, acute surgical planning need, locked joint, or rapidly progressive symptoms.)

(If prior study reports are unavailable from outside facilities, document retrieval attempts and label any patient-reported information as such.)

Assessment and Clinical Question

Working Diagnosis: [Confirmed / Suspected] [Diagnosis] — [One-line justification integrating symptoms, exam, and prior tests]

Differential Diagnoses: [Top 2–4 differentials that imaging will help distinguish]

Clinical Question: [Evaluate for / Confirm or exclude / Assess extent of] [specific suspected structure or condition] [for surgical planning / procedural guidance if applicable]

Planned Next Step if Findings Support Diagnosis: [Referral / surgery / injection / medication change / avoidance of invasive testing / other management change]

Medical Necessity Rationale

• [Link between current symptoms, objective findings, and why advanced imaging is needed now for the suspected pathology]
• [Why this modality over alternatives: MRI vs CT vs ultrasound vs radiographs for the clinical question]
• [How results will change management: determine surgical candidacy, guide intervention, expedite referral, or avoid invasive testing]
• [Summary of prior workup and conservative measures with dates demonstrating insufficiency or contraindication]
• [Clinical decision support or appropriate use criteria consulted: tool name and output] (Only include if applicable)
• [If resubmission after denial: new clinical information since prior request] (Only include for re-reviews or appeals)

Safety Considerations

(Include only if relevant to the requested study. Omit entire section if no safety considerations apply.)

• MRI device/metal/foreign body risk: [Yes / No / Unknown] (If unknown, state verification plan)
• Claustrophobia: [Yes / No] (If yes, state mitigation plan)
• Prior contrast reaction: [None / Mild / Severe] [Agent type: iodinated / gadolinium] (If prior reaction, state premedication plan)
• Renal risk: [eGFR value and date] [CKD status if applicable]
• Pregnancy status: [Not pregnant / Pregnant / Unknown] (Include for CT; state verification plan if unknown)

Attachments

• [List of supporting documents included: office notes, PT evaluation, prior imaging reports, specialist notes, EMG/NCS, labs]

(For any attachment containing a key approval criterion, summarize that criterion in the request body above so approval does not depend on deep chart review.)

Provider Attestation and Contact

Ordering Clinician: [Name], [Credentials], NPI: [NPI]

Signature: [Signature] Date: [Date]

[Attestation statement that the ordering clinician is treating the patient for this condition and will use imaging results to guide management]

(If expedited, include statement of specific medical risk if imaging is delayed.)

Peer-to-Peer Contact: [Callback number], [Preferred time window]