Prior Authorization Request (Cardiology)

Administrative Header

Request Type: [Medication PA / Diagnostic Test PA / Procedure PA / Renewal / Appeal]

Patient: [Full name], DOB: [DOB], Member ID: [Payer Member ID]

Payer: [Payer name], [Commercial / Medicare Advantage / Medicaid], [PBM or utilization vendor if known]

Ordering Clinician: [Name], [Credentials], NPI: [NPI], [Specialty], Phone: [Phone], Fax: [Fax]

Facility/Site of Service: [Facility name or TBD if not yet determined]

Urgency: [Standard / Expedited] (If expedited, include one-sentence clinical justification.)

Requested Service: [Specific medication with dose, route, frequency, duration OR diagnostic test name with CPT/HCPCS OR procedure name with CPT/HCPCS]

Diagnosis Codes: [Primary ICD-10-CM]; [Secondary ICD-10-CM codes if applicable]

Requested Authorization Window: [Start date] – [End date]

Attachments: [List supporting documents actually submitted]

Request Summary

[Concise 4–8 sentence medical necessity summary including: specific request; primary diagnosis with current severity or functional class; key objective findings with dates; guideline-directed or conservative therapies completed; why alternatives are inappropriate; and why this is necessary now with concrete risks of delay.] (Write as a single paragraph suitable for pasting into payer portals. This section should stand alone as a complete summary.)

Clinical Indication

Primary Diagnosis: [Diagnosis] ([ICD-10-CM]), onset [date if known]

Current Severity: [Severity classification using standard framework as applicable: EF with date and NYHA class for heart failure; CCS class for angina; severity grade with key echo parameters and date for valvular disease; arrhythmia type, burden, and control status for rhythm disorders]

Symptoms and Functional Impact: [Current symptoms, frequency, triggers, exertional limitations, impact on daily activities] (Quantify when documented.)

Relevant Comorbidities: [Only conditions affecting indication, urgency, or safety with objective values and dates] (Include pertinent negatives only if they affect coverage criteria. Omit if none relevant.)

Prior Therapy and Step Requirements

(Document therapies relevant to step therapy or guideline-directed management. For each therapy, include drug/class, dose, duration, clinical response, adherence documentation, and adverse effects or contraindication rationale if applicable. If external records are incomplete, state that details are unavailable rather than imputing dose or duration.)

• [Drug/class or intervention]: [Dose], [start date – end date or ongoing], [response: ineffective / partially effective / effective], [adherence: fill history / patient report / clinician assessment], [adverse effects with symptoms and severity if applicable], [contraindication rationale with supporting data if used to bypass preferred step]
• [Additional therapy]: [Same format as above] (Repeat as needed.)
• Lifestyle/Conservative Measures: [Document if commonly required by payers for this request type] (Omit if not applicable.)

Supporting Objective Data

(Include only data necessary to justify this request. Each item must include date and key result. Omit categories not relevant. Note pending results with facility and expected availability.)

• Vital Signs/Exam: [Key findings with dates]
• ECG: [Rhythm, intervals, ischemic changes with date]
• Echocardiography: [EF, chamber dimensions, wall motion, valve parameters with date]
• Stress Testing: [Modality, adequacy, ischemia extent/location, symptoms with date]
• Coronary/Anatomic Imaging: [CTA or angiography findings, stenosis severity, calcium score with date]
• Rhythm Monitoring: [Arrhythmia type and burden, monitoring duration and device with date]
• Laboratory: [BNP/NT-proBNP, troponin, lipids, eGFR, A1c, INR as relevant with dates]
• Prior Cardiac Procedures: [Procedure, date, outcome]

Criteria Alignment

Policy/Guideline Referenced: [Payer policy name and date, or guideline/appropriate use criteria title and year]

• [Criterion 1]: [Met / Not Met / N/A] — [One-line supporting evidence with date]
• [Criterion 2]: [Met / Not Met / N/A] — [One-line supporting evidence with date]
• [Criterion 3]: [Met / Not Met / N/A] — [One-line supporting evidence with date]

(Add or remove criteria lines as needed to match payer requirements.)

Medical Necessity Rationale

[Focused narrative addressing: the clinical question or therapeutic goal; why preferred alternatives are insufficient; why this option is appropriate now; expected benefit relative to risk; and concrete consequences of delay or denial.] (Be concise and problem-oriented. Do not introduce information not documented in the medical record.)

Shared Decision-Making

[Documentation that benefits, risks, and alternatives were discussed with patient; patient preferences or goals relevant to the decision; formal decision aid used if applicable]

(Include this section only when required by payer policy, such as for certain device implantations. Otherwise omit entirely.)

Follow-Up and Contact

Next Steps: [Actions contingent on authorization and anticipated timing]

Peer-to-Peer Contact: [Clinician name], [Direct phone], [Availability]

Additional Documentation Available: [For appeals: specify what else can be provided] (Omit if not an appeal.)

Attestation

I attest the above information is accurate to the best of my knowledge and supported by the medical record.

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

Signature: _________________________ Date: [Date]