Prior Authorization Request (Antineoplastic Therapy)

Request Type: [Initial PA / Continuation / Dose Change / Site-of-Care Change / Appeal]

Priority: [Standard / Expedited-Urgent] (If Expedited-Urgent, ensure justification appears in Time Sensitivity and Executive Summary.)

Requested Start Date: [Date]

Payer: [Payer name]; [Plan type: commercial / Medicare Advantage / Medicaid]; [Member ID]; [Group ID if applicable]

Ordering Provider: [Name, credentials]; [NPI]; [Phone]; [Fax]

Facility: [Name]; [NPI if required]

Patient: [Name]; [DOB]; [Member ID]

Executive Summary

• [Primary cancer diagnosis with histology/subtype and primary site] — [ICD-10 code if known]
• [Current stage/disease status] — [Sites of disease if metastatic]
• [Line of therapy for this request] — [Prior lines completed with brief descriptors]
• [Key biomarkers guiding selection: test name, result, date] (If pending, state test ordered, expected date, and whether regimen is contingent or bridging.)
• [Requested regimen and intent] — [Cycle length and schedule summary]
• [Why therapy is needed now: progression / recurrence / toxicity / completion / adjuvant window] — [Objective evidence with date]
• [Urgency statement with clinical harm and critical window] (Include only if Priority is Expedited-Urgent.)

Diagnosis and Disease Status

Primary diagnosis: [Diagnosis] — [ICD-10 code if known]

Histology/subtype: [Histology/subtype]; Date of initial diagnosis: [Date or approximate month/year]

Current stage/disease category: [AJCC/TNM if applicable; otherwise localized / locally advanced / metastatic / relapsed / refractory]; Staging basis: [Imaging / Pathology / Clinical] — [Date]

Sites of disease: [List sites with imaging dates] (Include if metastatic.)

• Pathology: [Specimen site]; [Procedure type]; [Report date]; [Key findings including grade, receptors/mutations if applicable]
• Imaging evidence: [Modality]; [Date]; [Pertinent findings quantifying burden or progression]
• Tumor markers: [Marker] — [Values with dates showing trend] (Include only if clinically used for this malignancy.)
• Performance status: [ECOG / Karnofsky] — [Date assessed]
• Organ function relevant to regimen safety: [Renal: Cr, eGFR — date]; [Hepatic: AST/ALT, bilirubin — date]; [Hematologic: ANC, Hgb, Plt — date] (Include only values pertinent to safety thresholds for requested regimen.)
• Comorbidities/contraindications affecting regimen choice: [List with brief relevance and dates of key events]
• Pending studies impacting regimen: [Test name]; [Ordered date]; [Expected date]; [Whether regimen is contingent vs. bridging approach] (Omit if none pending.)

Prior Therapies and Outcomes

(Include for non–first-line requests. Explicitly connect prior failures to step-therapy criteria where applicable.)

Line	Regimen	Dates	Best Response — Evidence Source	Reason Stopped
[Line number]	[Regimen name]	[Start – Stop]	[CR / PR / SD / PD] — [Imaging / lab / symptom source, date]	[progression / toxicity / completion / other]; [Toxicity type and grade if applicable]

(Add rows as needed for additional lines of therapy.)

• Residual or unresolved toxicities affecting future therapy: [List with current grade/severity and dates]
• Relevant surgery: [Procedure]; [Date]; [Key outcome: margins/pathology] (Include only if impacts current request.)
• Relevant radiation: [Site/dose/fractions]; [Dates]; [Response/toxicity] (Include only if impacts current request.)

Requested Therapy

Regimen: [Regimen name and components]

Indication: [Diagnosis]; [Stage/disease status]; [Line of therapy]

Intent: [curative / adjuvant / neoadjuvant / consolidation / maintenance / palliative]

Route and Setting: [IV / SC / oral]; [infusion center / specialty pharmacy / home infusion]

Dosing and Schedule: [Cycle length]; [Days of administration]; [Frequency]; [Planned number of cycles or duration criteria]

Patient metrics for dosing: [Weight with date]; [Height with date]; [BSA with date] (Include if weight/BSA-based dosing.)

Planned dose adjustments: [Adjustments for renal/hepatic impairment or other factors with clinical rationale] (Include only if applicable.)

For oral agents: [Daily dose]; [Quantity/days supply]; [Refills requested] (Include only for oral oncolytics.)

Drug codes: [HCPCS J-code]; [NDC] (Include if required by payer.)

Supportive care relevant to approval: [Required premedications]; [Growth factor support]; [Prophylaxis required by regimen] (Omit routine items not tied to approval criteria.)

Medical Necessity Rationale

• Guideline/compendia basis: [Guideline or compendia name, version, date] — [Category/level of evidence if applicable] (If off-label, explicitly state and cite compendia category or peer-reviewed literature.)
• Patient-specific eligibility alignment: [Stage/disease status]; [Biomarker status with dates]; [Prior lines completed]; [Contraindications to alternatives]; [Organ function parameters meeting safety thresholds]
• Alternative therapies and why not appropriate:
  • [Alternative 1] — [Reason: prior failure with date / contraindication / inferior efficacy for biomarker profile / unacceptable toxicity risk]
  • [Alternative 2] — [Reason not appropriate]
  • [Additional alternatives as relevant]
• For continuation requests: [Objective benefit: radiographic / biochemical / symptomatic response with evidence and dates]; [Current tolerability and toxicity management]; [Why continuation is medically necessary vs stopping/switching] (Include only for continuation requests.)
• For non-preferred product/site exceptions: [Clinical reason: prior reaction, documented medical exception, device/administration constraints, site-of-care safety considerations] (Include only if requesting non-preferred product or site.)

Safety and Monitoring Plan

• Baseline assessments completed: [Labs with dates]; [Cardiac imaging if applicable with date]; [Screening tests with dates]
• On-treatment monitoring: [Lab frequency]; [Imaging/response assessment cadence]; [Toxicity monitoring approach]
• Dose modification strategy: [General thresholds for hold/reduce/discontinue per guideline or label] (Summarize at high level; do not paste full protocol.)

Time Sensitivity

• Objective trigger: [Imaging or clinical finding with date showing progression, organ compromise, or symptomatic burden]
• Clinical window: [Specific timeframe and consequence of delay, e.g., "Delay beyond X days/weeks risks loss of curative window / organ failure / hospitalization"]

(For Standard priority requests, note relevant timing such as adjuvant start goal post-operatively or surveillance interval. For Expedited-Urgent, must include patient-specific harm statement with objective data.)

Supporting Documentation

• [Pathology report — date — Confirms diagnosis/histology/subtype]
• [Molecular/biomarker report — date — Lists actionable markers guiding therapy] (Note if pending with expected date.)
• [Imaging report(s) — date — Staging or progression documentation]
• [Recent clinic note — date — Performance status and treatment discussion]
• [Pertinent labs — date — Baseline organ function/safety parameters]
• [Prior treatment records — date — Document prior lines and reasons for discontinuation] (Include if from outside facility.)
• [Guideline/compendia citation — name, version, date] (Metadata only.)
• [Peer-reviewed literature citation] (Include only if needed for off-label support.)

Attestation

Ordering Clinician: [Name, credentials, NPI]

Date Signed: [Date]

Peer-to-Peer Contact: [Name/role]; [Phone]; [Available hours]