Prior Authorization Request (Anti-VEGF Medication)

Request Type: [Initial / Reauthorization / Dose or Interval Exception / Step-Therapy Exception / Appeal Support]
Urgency: [Standard / Urgent/Expedited] [Brief reason if urgent]
Patient Name: [Patient name]
Date of Birth: [DOB]
Member ID: [Member ID]
PA/Claim Reference: [Reference number] (Include only if resubmission)
Requesting Provider: [Name, credentials, NPI]
Practice Contact: [Phone, fax, address]
Site of Care: [Office / ASC / HOPD]

Requested Anti-VEGF Medication and Dosing Plan

Medication: [Brand name (generic name); formulation/strength]
Route: Intravitreal injection
Eye(s): [OD / OS / OU]
Dose and Frequency: [Dose] [q4w / q6w / q8w / q12w / treat-and-extend]; [loading phase / maintenance]
Authorization Period: [Duration requested]
Quantity: [Number of doses per eye]
Billing Codes: [HCPCS/J-code, or "to be provided by billing"]

Exception Rationale: [Dated objective evidence supporting non-standard frequency or different agents for different eyes on same date] (Include only if requesting non-standard frequency or different agents same date)

Diagnoses and Severity

Right Eye (OD)

• Primary Diagnosis: [Diagnosis] [ICD-10-CM code with laterality]
• Onset/Course: [New / Chronic]; [Date of diagnosis or key milestone]
• Severity/Current Status: [Current BCVA with date and trend]; [Center-involving edema / subfoveal involvement / active exudation / hemorrhage / recurrence at extended interval with dates]
• Key Comorbidities: [Ocular or systemic factors influencing agent selection or risk] (Include only if materially relevant)

Left Eye (OS)

• Primary Diagnosis: [Diagnosis] [ICD-10-CM code with laterality]
• Onset/Course: [New / Chronic]; [Date of diagnosis or key milestone]
• Severity/Current Status: [Current BCVA with date and trend]; [Center-involving edema / subfoveal involvement / active exudation / hemorrhage / recurrence at extended interval with dates]
• Key Comorbidities: [Ocular or systemic factors influencing agent selection or risk] (Include only if materially relevant)

(Omit eyes not being treated. Do not state disease activity without dated objective evidence.)

Objective Findings Supporting Medical Necessity

Right Eye (OD)

• Visual Acuity ([Date]): [BCVA]; trend: [Prior BCVA] ([Prior date]) → [Current BCVA] ([Current date])
• OCT ([Date]): [Intraretinal fluid / Subretinal fluid / PED / Cystoid spaces]; CST [value if available]; [Subfoveal involvement]; vs prior ([Date]): [Improved / Stable / Worsened]
• Angiography/Fundus Photos ([Date]): [Key findings establishing diagnosis or activity] (Include only if used)
• Clinical Exam ([Date]): [Hemorrhage / Exudates / Neovascularization / Vitreous hemorrhage]

Interpretation (OD): [Brief statement linking findings to the requested agent and interval] (If imaging unobtainable, state reason and alternate diagnostic method)

Left Eye (OS)

• Visual Acuity ([Date]): [BCVA]; trend: [Prior BCVA] ([Prior date]) → [Current BCVA] ([Current date])
• OCT ([Date]): [Intraretinal fluid / Subretinal fluid / PED / Cystoid spaces]; CST [value if available]; [Subfoveal involvement]; vs prior ([Date]): [Improved / Stable / Worsened]
• Angiography/Fundus Photos ([Date]): [Key findings establishing diagnosis or activity] (Include only if used)
• Clinical Exam ([Date]): [Hemorrhage / Exudates / Neovascularization / Vitreous hemorrhage]

Interpretation (OS): [Brief statement linking findings to the requested agent and interval] (If imaging unobtainable, state reason and alternate diagnostic method)

Previous Treatments and Response

Right Eye (OD)

• Anti-VEGF History: [Agent(s); date range; number of injections; intervals attempted]
• Response: [VA change with dates]; [Anatomical response with dates]
• Treatment Failures: [Recurrence at extended interval / Persistent fluid / Inability to maintain gains] with dates
• Adverse Events/Intolerance: [Details] (Include only if relevant)
• Other Prior Therapies: [Laser / PRP / Steroids]; [Reason not suitable now] (Include only if relevant)

Left Eye (OS)

• Anti-VEGF History: [Agent(s); date range; number of injections; intervals attempted]
• Response: [VA change with dates]; [Anatomical response with dates]
• Treatment Failures: [Recurrence at extended interval / Persistent fluid / Inability to maintain gains] with dates
• Adverse Events/Intolerance: [Details] (Include only if relevant)
• Other Prior Therapies: [Laser / PRP / Steroids]; [Reason not suitable now] (Include only if relevant)

Step-Therapy Exception: Payer-required agent: [Agent name]. Not appropriate because: [Inadequate response after reasonable trial (specify agent, dose, interval, duration) / Contraindication or intolerance / Patient-specific clinical risk with details] (Include only if step-therapy exception is being requested)

(If prior treatment records are incomplete: "Prior injection records requested from [facility]; partial data available: [Brief summary]")

Medical Necessity Rationale

[Concise synthesis in 5–8 sentences: Summarize diagnosis and current disease activity by eye; state vision-threatening risk and functional impact; cite objective evidence with dates (VA trends, OCT/angiography); summarize prior treatment course and response; justify the specific requested agent and interval, including why alternatives are not suitable if applicable; outline planned monitoring and reassessment approach]

Urgency and Timing

Next Planned Injection Date: [Date]
Clinical Reason Timing Matters: [Recurrent fluid / Monocular status / Rapid decline] with dated evidence
Consequence of Delay: [Specific risk statement, e.g., "Delay beyond [date] increases risk of permanent vision loss"]

(Include this section only when timing is clinically significant; omit for routine renewals)

Safety and Consent

• Off-Label Use: [Off-label use acknowledgment and consent documented for bevacizumab] (Include if applicable)
• Relevant Safety Considerations: [Allergies or prior intraocular inflammation history] (Include if applicable)
• Pregnancy/Lactation: [Considerations] (Include if pertinent)
• Informed consent is documented and on file.

(Include this section only when applicable)

Attached Supporting Documentation

• OCT report/images [OD / OS] ([Date])
• Angiography report/images [OD / OS] ([Date]) (If used)
• Prior injection record [OD / OS] ([Date range])
• Relevant clinic note excerpt [OD / OS] ([Date])

Provider Attestation and Signature

I attest that the information provided above is accurate and supported in the medical record.

Provider Signature: [Signature]
Name/Credentials: [Name, credentials]
NPI: [NPI]
Date: [Date]
Peer-to-Peer Contact: [Direct phone number]; Availability: [Preferred days/times]