Prior Authorization Request (Diagnostic Test)

Submission Date: [Submission date] (Required; if unknown, enter "Unknown")
Request Type: [Initial / Renewal / Resubmission / Appeal]
Review Urgency: [Standard / Expedited] (If Expedited, include one-sentence clinical risk of delay)
Payer: [Payer name and plan type if known]
Member ID / Group ID: [Member ID] / [Group ID] (If required by payer and unknown, enter "Unknown")
PA Reference Number: [Reference number] (Include only for Resubmission or Appeal)
Patient: [Full name], [DOB], [Sex]
Ordering Clinician: [Name, credentials, NPI, practice name, phone, fax]
Peer-to-Peer Contact: [Name, direct phone, available times] (Omit if unknown)
Rendering Facility: [Facility name and NPI] (Omit if not yet determined)

Test Requested

Test Name: [Plain-language test name with laterality, anatomic region, and technique as applicable]
Formal Name/Protocol: [Formal test name and protocol specifics—contrast status/type, analyte/panel, or cardiac/neurodiagnostic protocol]
CPT/HCPCS Code(s): [Code(s)] (If unavailable, note "Pending—will complete prior to submission")
ICD-10-CM Diagnosis Code(s): [Primary code; relevant secondary codes] (If unavailable, note "Pending—will complete prior to submission")
Clinical Question: [One sentence stating the management decision that depends on this result] (Avoid vague "rule out" phrasing)
Timing: [Desired completion window or frequency] (Include only if clinically relevant)

Medical Necessity Summary

(Provide a concise 3–6 sentence summary focused on necessity and safety)

• [Condition being evaluated with severity/acuity]
• [Key positive objective findings and any red flags]
• [Highlights of prior workup and treatments with dates]
• [Why this test is the appropriate next step now]
• [Specific management decision that will change based on the result]

Clinical History and Prior Workup

[Presenting problem: onset, timeline, severity, and functional impact; pertinent associated symptoms including clinically meaningful negatives explicitly obtained] (Do not infer negatives)

[Targeted exam findings supporting medical necessity] (If no exam performed, state this and reference objective findings from available sources)

Prior Diagnostics

• [Date — Test name — Key findings — Why insufficient or why further evaluation is required]
• [If prior approved study was not completed: brief explanation]
• [Patient-reported prior testing: summary and records-request status] (Include only if applicable)

Prior Treatments and Step Therapy

(Include when step therapy documentation is expected; omit for acute trauma or emergent presentations where conservative management is not indicated)

• [Medication trials: agent, dose, duration, response/adverse effects]
• [Non-pharmacologic therapy: dates, number of sessions, response]
• [Relevant procedures/interventions and outcomes]
• [If conservative therapy not attempted: rationale—red flags, suspected urgent condition, or contraindications]

Diagnostic Rationale

Primary Suspected Diagnosis: [Diagnosis]
Key Differentials: [2–4 plausible alternatives the test will help discriminate]
Why This Test: [Brief explanation of how the test answers the clinical question or differentiates among conditions]
Guideline Support: [Appropriateness guideline or society recommendation with one-sentence mapping of patient facts to criteria] (If none applicable, state "Decision based on clinical findings")
Alternatives Considered: [Alternative modality or approach and why inadequate for this patient]

Risk, Benefit, and Safety

(Include only when test carries meaningful patient-specific risk—contrast, radiation, sedation, invasive procedure, genetic testing—or payer policy requires it; omit for negligible-risk tests)

• [Contrast-related risks: reaction history, premedication plan, latest creatinine/eGFR with date] (If unknown, note "Will obtain prior to scheduling")
• [Radiation exposure considerations and justification]
• [Pregnancy status and plan if relevant]
• [Device/implant compatibility for MRI and confirmation plan]
• [Sedation/anesthesia needs and safety plan]
• [Genetic testing: consent/counseling status if applicable]
• [Expected benefit tied directly to the management decision]

Management Plan Contingent on Results

(Map anticipated result categories to specific actions; do not imply certainty about which result will occur)

If abnormal/positive: [Planned intervention, referral, or treatment change with timeframe]

If equivocal: [Next diagnostic step—repeat test, alternate modality, or specialist review]

If normal/negative: [Planned action—alternative workup direction, continued conservative management, or conclude evaluation]

Supporting Documentation

• [Most recent signed clinic note supporting the request with date]
• [Relevant prior imaging, lab, or neurodiagnostic reports with dates]
• [PT notes or discharge summary if failed conservative management is claimed]
• [Prior denial letter and response addendum] (For resubmission/appeal only)
• [Other pertinent attachments] (If an expected attachment is unavailable, note reason and when it will be provided)

Attestation

"I am the treating clinician for this condition and will use the results to guide management. The requested test is medically necessary for the indication described."

Signature: [Name, credentials, NPI, date]

(For resubmissions or appeals: Include addendum summarizing the payer's denial reason and point-by-point response addressing each concern)