Prior Authorization Request (Antineoplastic Therapy)

Patient: [Full name], DOB: [DOB], MRN/Member ID: [MRN or member ID]
Insurance: [Payer/plan name], Member ID: [Member ID], Group ID: [Group ID / Not applicable]
Request Type: [Initial / Renewal / Appeal]; Benefit: [Medical / Pharmacy]; Site of Care: [Infusion center / Hospital outpatient / Home infusion / Specialty pharmacy]; Requested Start Date: [Date]
Ordering Provider: [Clinician name, credentials], NPI: [NPI], Facility: [Facility name], Phone: [Phone], Fax: [Fax]
Review Type: [Standard / Expedited-Urgent]

Executive Summary

• [Primary cancer diagnosis with histology and molecular subtype; source document and date]
• [Stage or risk category with staging system, date, and source]
• [Line of therapy, e.g., 1L adjuvant, 2L metastatic]
• [Requested regimen with generic drug names, cycle length, and schedule]
• [Critical biomarker results with test dates]
• [Prior therapy summary: most recent regimen, best response, reason stopped, dates]
• [Guideline concordance statement with version and category]
• [Off-label/exception basis if applicable: compendia category or key literature]
• [Time sensitivity if expedited review requested]

(Limit to 6–10 bullets. Every clinical claim should reference source document and date.)

Requested Therapy

Drug (generic)	Route	Dose and Calculation Method	Schedule	Planned Duration/Cycles	HCPCS/J-code or NDC	ICD-10 Code(s)
[Drug 1 generic]	[IV / PO / SC]	[Dose with units and method; patient parameters: height, weight, BSA, renal function if relevant; dose caps if applicable]	[Days administered; cycle length]	[Number of cycles or duration]	[Code]	[ICD-10]
[Drug 2 generic]	[IV / PO / SC]	[Dose with units and method; patient parameters]	[Schedule]	[Duration/cycles]	[Code]	[ICD-10]
[Additional drugs as needed]	[Route]	[Dose with calculation]	[Schedule]	[Duration/cycles]	[Code]	[ICD-10]

Requested Authorization Period: [e.g., 6 cycles, 3 months, or specific end date]

Planned Dose Modifications: [None planned / Planned modifications with clinical justification and supporting labs/dates]

Continuation/Renewal: [Treatment response/stability status, tolerability, and treatment dates to date with most recent assessment date] (Include only for renewal requests)

Cancer Diagnosis and Disease Status

Diagnosis: [Primary site], [Histology/subtype], [Grade if relevant]; Initial diagnosis: [Date]; Metastatic/recurrent diagnosis: [Date if different]; Source: [Document type and date]

Stage/Risk: [AJCC stage and metastatic sites for solid tumors / Risk stratification system and category for hematologic malignancies]; Source: [Document type and date]

Current Status: [Current disease burden and sites]; [Progression or response status with imaging type and date]; [Relevant tumor markers with values and dates] (Include only details supporting this request)

Biomarkers and Eligibility

Biomarker/Test	Result	Specimen Type and Collection Date	Method/Platform	Performing Lab	Report Date
[Test name]	[Result]	[Specimen; date]	[Method]	[Lab]	[Date]
[Test name]	[Result / Pending / Not tested]	[Specimen; date]	[Method]	[Lab]	[Date / Expected date]

Eligibility Mapping: [Statement linking patient's biomarker profile to therapy indication, e.g., "Meets indication: EGFR exon 19 deletion + metastatic NSCLC + progression after prior therapy"]

(For pending biomarkers: state expected date and whether treatment awaits results. For biomarkers not tested: state reason. Do not leave fields blank.)

Prior Treatment History

Regimen (generic names)	Dates (start–stop)	Best Response	Reason Stopped
[Most recent regimen]	[Start–stop dates]	[CR / PR / SD / PD / Not evaluable]	[Progression / Toxicity (grade) / Completed / Other]
[Prior regimen or local therapy]	[Start–stop dates]	[Best response]	[Reason stopped]

(List in reverse chronological order. Include relevant local therapies.)

Prior Exposure to Requested Drug/Class: [Yes / No] — [Details including dates, response, and tolerability if yes]

Clinical Status

• ECOG Performance Status: [0 / 1 / 2 / 3 / 4] ([Date assessed])
• Anthropometrics: Weight [kg], Height [cm], BSA [m²] ([Date]) (Include if dosing is weight- or BSA-based)
• Relevant Baseline Labs: [CBC, CMP, LFTs, creatinine/eGFR values with dates] (Include only labs pertinent to regimen safety/dosing or payer criteria)
• Pertinent Comorbidities/Contraindications: [List with relevance to regimen]
• Pregnancy Status: [Negative / Not applicable] ([Test date]) (Include only for teratogenic agents)

Medical Necessity Rationale

[3–4 sentence rationale: clinical problem requiring treatment; why this regimen is appropriate for this patient at this line; why alternatives are not appropriate; expected clinical benefit]

Guideline Alignment: [Guideline name, version, date]; Use category: [FDA-labeled / Compendia-supported off-label (category) / Literature-supported exception]

Policy Criteria Mapping:

• Criterion: [Payer requirement] → Evidence: [Patient documentation with dates and source]
• Criterion: [Step therapy/prior lines requirement] → Evidence: [Prior regimen, response, progression documentation with dates]
• Criterion: [Biomarker requirement] → Evidence: [Result with method, lab, report date]
• Criterion: [Line-of-therapy or setting requirement] → Evidence: [Supporting documentation with dates]

Alternatives Considered:

• [Alternative 1] — [Reason not appropriate for this patient]
• [Alternative 2] — [Reason not appropriate]
• [Alternative 3] — [Reason not appropriate] (Include 1–3 alternatives as relevant)

Urgency Justification

(Complete only for expedited review requests)

Clinical Triggers: [Rapid progression with imaging date / Symptomatic disease or organ compromise / Narrow treatment window]; Latest Acceptable Start Date: [Date]; Consequences of Delay: [Brief statement]

Attachments

• Pathology report ([Date])
• Biomarker/molecular report(s) ([Date])
• Imaging report documenting stage/progression ([Date])
• Recent oncology clinic note ([Date])
• Prior treatment records ([Dates])
• Relevant baseline labs ([Dates])
• Guideline excerpt or key literature (For off-label/exception requests)

(If a typical attachment is unavailable, note reason and expected availability)

Attestation and Contact

Attestation: I attest that the above information is accurate and complete and supports medical necessity for the requested therapy.

Peer-to-Peer Contact: [Provider name], Phone: [Direct number], Availability: [Days/times with time zone]

Signature: ________________________________ Date: ____/____/______