Prior Authorization Request (Anti-Obesity Medication)

Submission Type: [Initial / Renewal / Appeal]

Date of Submission: [Date]

Requested Start Date: [Date]

Urgency: [Standard / Expedited] (If expedited, include brief clinical rationale: [Rationale for expedited review])

(Include the following field only for Renewal or Appeal submissions; omit for Initial submissions)

PA Reference Number: [Reference number from prior authorization]

Payer Information

Plan Name: [Plan name]

PBM: [PBM name / Unknown—verification pending]

Payer Phone/Fax/Portal: [Contact information]

Patient Information

Name: [Patient full name]

Date of Birth: [Date of birth]

Member ID: [Member ID]

Group ID: [Group ID]

Phone: [Patient phone]

Prescriber Information

Clinician Name and Credentials: [Name, credentials]

Specialty: [Specialty]

NPI: [NPI]

Practice Address: [Street, City, State, ZIP]

Phone/Fax: [Phone / Fax]

Contact Person for PA Questions: [Name and contact details]

Medication Request

Drug Name (Brand/Generic): [Requested AOM name]

Formulation and Route: [Formulation and route of administration]

Starting Dose: [Dose and frequency]

Titration Schedule: [Stepwise titration plan and intervals]

Target Maintenance Dose: [Dose and frequency]

Quantity and Days Supply: [Quantity] for [Days supply]

Refills Requested: [Number of refills]

Diagnosis Codes (ICD-10-CM): [Primary obesity diagnosis code, BMI code if required by payer, additional codes if applicable]

Primary Indication: [Chronic weight management / cardiovascular risk reduction / other FDA-approved obesity-related indication]

Executive Summary

(Provide 6–10 concise bullet points summarizing key elements; keep to one page maximum)

• Baseline: Weight [weight with units] on [date], Height [height], BMI [calculated value]
• Obesity classification: [Class I / II / III / Overweight with comorbidity]
• Key weight-related comorbidities: [Comorbidities with brief status]
• Prior lifestyle intervention: [Type, duration, and outcome with percent weight change]
• Prior AOM trials: [Medications tried with outcomes, or reasons not tried]
• Rationale for selected medication: [Mechanism fit, comorbidity alignment, payer criteria alignment]
• Request: [Drug, dose, titration schedule, and approval duration sought]
• (Renewals only) Treatment response: [Weight/BMI change, comorbidity improvements, adherence, tolerability; statement that continuation criteria are met]
• (Appeals only) Denial addressed: [Brief note that denial reasons are addressed in Response to Denial section with evidence mapping]

Clinical Indication and Anthropometrics

[Diagnosis: Obesity or Overweight with weight-related comorbidity] — [Requested indication per FDA labeling] — ICD-10-CM: [Codes]. Request basis: [BMI threshold alone / BMI plus comorbidities].

(If height is not documented, do not calculate BMI; state "BMI cannot be calculated—height not documented")

Measurement	Value	Date	Source
Height	[Height with units]	[Date]	[Clinic-measured / Patient-reported]
Weight	[Weight with units]	[Date]	[Clinic-measured / Patient-reported]
BMI (calculated)	[BMI value] (Calculation: [weight in kg] ÷ [height in m]² = [result])	[Date]	Derived from documented height/weight
Blood Pressure	[Value]	[Date]	[Source]
Heart Rate	[Value]	[Date]	[Source]
Waist Circumference	[Value] (omit row if not available)	[Date]	[Source]

Weight History

(Include at minimum: highest documented adult weight, current weight, and 3–6 data points showing trajectory)

Date	Weight	BMI	Context	Source
[Date]	[Highest documented adult weight]	[BMI / Not calculable if height unavailable]	[Context]	[Source]
[Date]	[Weight]	[BMI]	[Context]	[Source]
[Date]	[Weight]	[BMI]	[Context]	[Source]
[Date]	[Current weight]	[Current BMI]	[Context]	[Source]

[One-sentence interpretation of weight trajectory and response to prior interventions]

Percent weight change from baseline: ([Current weight] − [Baseline weight]) ÷ [Baseline weight] × 100 = [Result]%

Weight-Related Comorbidities

(List only diagnoses with documented diagnostic evidence; omit suspected conditions unless labeled with evaluation status)

• [Diagnosis name] — ICD-10-CM: [Code]
  • Objective evidence: [Labs, vitals, or studies with dates]
  • Current treatment: [Medications, therapies, or devices]
  • Clinical impact: [Functional impact or risk implications]
• [Additional comorbidities as above]

(If no documented weight-related comorbidities, state: "No documented weight-related comorbidities—request based on BMI threshold alone")

(If suspected condition without confirmed diagnosis, label as: "[Suspected condition]—evaluation pending: [pending tests or referrals]")

Prior Lifestyle Intervention

• Nutrition plan: [Description and date range]
• Physical activity plan: [Description and any limitations]
• Behavioral components: [Coaching, group sessions, self-monitoring, digital programs]
• Clinician supervision: [Yes / No; supervised by whom]
• Visit/session count: [Number if available]
• Objective outcome: Start weight [value] ([date]) → End weight [value] ([date]); % change = ([End] − [Start]) ÷ [Start] × 100 = [Result]%
• Barriers and why lifestyle alone insufficient: [Description]

(If documentation is sparse but patient reports prior efforts, label as: "Patient-reported lifestyle intervention history (not independently verified)—[any objective corroboration]")

(If no documented lifestyle intervention, state explicitly and provide rationale for proceeding with request)

Prior Pharmacotherapy for Weight

(If no prior AOM trials, state: "No prior anti-obesity medication trials—[reason: patient preference / access barriers / clinical decision / other]")

Drug Name	Dose Range	Duration (dates)	Response	Discontinuation Reason	Adverse Effects
[Drug]	[Dose range]	[Start date] – [End date]	[Baseline weight] → [End weight]; [% change] (or "Response not documented")	[Reason]	[Adverse effects experienced]
[Additional medications as needed]

Safety Screening

(Format: Item — [Reviewed / Present / Not Present / Unknown])

General screening:

• Pregnancy status — [Reviewed / Present / Not Present / Unknown]
• Lactation status — [Reviewed / Present / Not Present / Unknown]
• Pregnancy intention and contraception plan — [Reviewed / Present / Not Present / Unknown / Not applicable]
• History of severe allergic reaction to requested drug or class — [Reviewed / Present / Not Present / Unknown]
• Psychiatric history including suicidality risk — [Reviewed / Present / Not Present / Unknown]
• Substance use history — [Reviewed / Present / Not Present / Unknown]

Agent-specific screening (include items relevant to requested medication):

• Personal or family history of medullary thyroid carcinoma or MEN2 — [Reviewed / Present / Not Present / Unknown]
• History of pancreatitis — [Reviewed / Present / Not Present / Unknown]
• Gallbladder disease — [Reviewed / Present / Not Present / Unknown]
• Severe GI disease or gastroparesis — [Reviewed / Present / Not Present / Unknown]
• Renal impairment or dehydration risk — [Reviewed / Present / Not Present / Unknown]
• Diabetic retinopathy — [Reviewed / Present / Not Present / Unknown / Not applicable]
• Uncontrolled hypertension — [Reviewed / Present / Not Present / Unknown]
• Seizure history — [Reviewed / Present / Not Present / Unknown]
• Eating disorder history — [Reviewed / Present / Not Present / Unknown]

Concomitant therapy review:

• Insulin or secretagogue use: [Yes / No]. If yes, hypoglycemia management plan: [Dose adjustment, education, monitoring plan]
• Other weight-affecting medications or potential interactions reviewed: [Yes / No / Not applicable]

Unknown items verification: [Steps taken: patient interview / outside records requested / testing ordered] (Include expected completion dates if applicable)

Baseline monitoring and follow-up plan: Baseline completed: [List items and dates]. Follow-up interval: [Frequency]. Weight monitoring: [Cadence and method]. Lab monitoring: [As clinically indicated]. Stop rules: [Intolerable adverse effects / inadequate response per payer criteria after specified duration].

Medical Necessity Rationale

(Write in narrative format, approximately one page; use professional, non-adversarial language; align all statements with documented evidence in this packet)

[Diagnosis and severity of obesity including BMI class and risk profile. Complications and clinical risks related to obesity. Summary of prior conservative management attempts and outcomes. Rationale for requested therapy now, including mechanism fit to patient phenotype and comorbidities and alignment with FDA labeling. Why alternatives are inappropriate or have failed, including contraindications, intolerances, or step therapy requirements satisfied. Safety appropriateness and monitoring plan. Expected clinical benefits stated in measured terms. Consequences of non-treatment. Explicit request including approval duration, quantity, and dosing.]

Response to Denial (Appeal Only)

(Include this subsection only for Appeal submissions)

• Quoted denial reason(s): "[Payer's denial language verbatim]"
• Point-by-point rebuttal: [Map each denial criterion to specific evidence in this packet, citing sections, dates, results, and ICD codes]
• Guideline or labeling conflicts: [If payer criteria conflict with FDA labeling or professional guidelines, note discrepancy factually with references]

Response to Treatment (Renewal/Continuation Only)

(Include this section only for Renewal or Continuation submissions)

Metric	Baseline (date)	Current (date)	Change
Weight	[Baseline weight] ([Date])	[Current weight] ([Date])	[Absolute change]; [% change]
BMI	[Baseline BMI]	[Current BMI]	[Absolute change]
Waist Circumference (if available)	[Baseline]	[Current]	[Change]
[Relevant comorbidity marker, e.g., A1c, BP, lipids]	[Baseline] ([Date])	[Current] ([Date])	[Change]

Duration on therapy: [Start date] to present. Current dose: [Dose]. Adherence: [High / Moderate / Low] based on [pharmacy fills / patient report / device data]. Tolerability: [Side effects experienced and management].

[Statement whether payer continuation criteria are met, clinical response achieved, and why discontinuation would be medically inappropriate, including demonstrated response, improved risk markers, and documented weight regain risk]

(If objective response data are incomplete, document most recent available data and measurement plan: "[Patient scheduled for clinic weight on (date)]")

Attachments Index

(Include only documents necessary to support payer criteria; avoid indiscriminate chart forwarding)

1. [Document title] — [Date range] — [One-line description of relevance]
2. [Document title] — [Date range] — [One-line description of relevance]
3. [Additional supporting documents as needed]

Provider Attestation

• I attest that the information provided is accurate and derived from the medical record.
• The requested therapy is medically necessary and clinically appropriate for this patient.
• Contraindications and precautions have been reviewed and addressed.
• The patient has been counseled on risks, benefits, alternatives, and realistic expectations.
• A follow-up and monitoring plan is in place as outlined above.

Prescriber Signature: [Signature]

Date: [Date]

NPI: [NPI]

Contact Phone/Fax: [Phone / Fax]

(Meta-instructions: Omit sections that do not apply—omit Response to Treatment for Initial requests; omit Response to Denial unless Submission Type is Appeal. For critical missing information, use explicit placeholders: "Not documented in record," "Patient-reported only," "Outside records requested," or "Measurement scheduled." Do not infer diagnoses or outcomes without explicit documentation. Calculate BMI and percent weight change from documented values and show calculations. Keep Executive Summary to one page.)