Prior Authorization Request (Endoscopy Procedure)

Date of Request: [Date of request]

Request Type: [initial request / resubmission / appeal] (If resubmission or appeal, include prior denial date and specific denial reason verbatim from determination letter.)

Urgency: [routine / expedited] (If expedited, add concise clinical rationale demonstrating risk of delay.)

Payer: [Payer name], [Plan type], [Routing details: fax/portal and reference number if available]

Patient Name: [Patient full name]

Date of Birth: [DOB]

Member ID: [Member ID] (If required by payer but unavailable, enter "Unknown at time of submission"; omit field entirely if not required.)

Group Number: [Group number] (Include if known; omit if unknown.)

Requested Service(s) and Code Pairing Summary

Requested procedure: [EGD / colonoscopy / flexible sigmoidoscopy / EUS / ERCP] — [diagnostic / therapeutic]

Planned procedural components: [biopsy / polypectomy / dilation / hemostasis / stent placement / FNA / sphincterotomy / stone extraction / none anticipated] (Include only components that are planned or likely.)

Site of service: [ASC / HOPD / inpatient] (Include only if relevant to authorization.)

Sedation: [moderate sedation / MAC / general anesthesia] (Include only if relevant to authorization.)

Medical necessity statement: [One-sentence concrete justification linking the patient's indication, prior management, and need for endoscopy now]

CPT/HCPCS Code	Brief Descriptor	Primary ICD-10-CM	Secondary ICD-10-CM	Indication Category
[CPT/HCPCS]	[Procedural descriptor]	[Primary ICD-10-CM]	[Secondary ICD-10-CM or "—"]	[symptom-based / screening / surveillance / abnormal test]

(Add rows for each CPT requested. Each CPT must pair with at least one specific ICD-10-CM that is not a vague "rule out" code. Omit modifiers if unknown.)

Clinical Indication(s) for Endoscopy

Primary indication: [Concise description of the main reason endoscopy is needed now]

• Symptom profile: [Onset, duration, trajectory, severity, frequency, functional impact] (Include for symptom-based indications.)
• Alarm features pertinent to this case: [Specify each relevant alarm feature as present or absent: dysphagia, unintentional weight loss, GI bleeding, iron deficiency anemia, persistent vomiting] (List only features pertinent to this presentation. If not fully assessed, state: "Alarm features not fully assessed in available records; will assess prior to procedure.")
• Relevant risk factors: [Age, family history of GI malignancy, IBD history, smoking, obesity, Barrett's esophagus, other] (Include only if relevant to the indication.)
• Objective abnormality prompting evaluation: [Specific finding with values, units, and dates] (Include for abnormal test indications: positive FIT/FOBT, imaging abnormality, lab-defined iron deficiency anemia.)
• Screening/surveillance context: [Asymptomatic average-risk screening / Surveillance indication with prior history and interval rationale] (Include for screening or surveillance indications.)

Secondary indication(s): [Additional clinically relevant indications] (Omit if none.)

Prior Management and Diagnostic Evaluation

(Include this section when conservative management or prior workup is relevant to the indication or likely required by payer criteria. Omit or abbreviate if the indication is inherently urgent, and instead document why delay is unsafe in the Urgency section.)

• Medication trial(s): [Drug name, dose, frequency, start date, stop date or ongoing, adherence, optimization steps, clinical response] (For GERD-type indications, an adequate PPI trial is typically 8 weeks at optimized dosing.)
• Lifestyle measures attempted: [Specific measures and duration] (Include only if actually attempted and documented.)
• Noninvasive testing completed: [Test name, date, result] for each relevant test (e.g., H. pylori testing, FIT/FOBT, CBC with hemoglobin trend, ferritin/iron studies, celiac serologies, relevant imaging)
• Prior endoscopy: [Date, key findings, pathology results, reason repeat evaluation is now indicated] (Include if applicable.)
• If conservative trial not performed: [Contraindication/intolerance / Alarm feature warranting expedited evaluation / Prior adequate trial documented elsewhere] (Briefly justify when a typically required trial was not done.)

Relevant Medical History

(Include only history that affects medical necessity, procedural safety, or site-of-service determination. Omit unrelated chronic conditions. Do not infer medication status as absent unless verified.)

• Anticoagulants/antiplatelets: [Agent, indication, peri-procedural management plan] (Include if relevant to procedural planning.)
• Cardiopulmonary comorbidities affecting sedation: [Conditions and current status]
• Prior anesthesia/sedation complications: [History and relevance]
• Relevant allergies: [Sedation agents, antibiotics if prophylaxis anticipated, contrast; include reaction type]
• Pregnancy status: [Status] (Include if relevant to sedation or imaging.)
• Other safety-relevant factors: [OSA, renal insufficiency affecting bowel prep, implanted devices] (Include only if relevant.)

Clinical Assessment and Medical Necessity Rationale

Working diagnosis: [Symptom- or condition-based assessment aligned with the indication]

Differential diagnosis: [Condition 1], [Condition 2], [Condition 3] (List 2–5 conditions the endoscopy is intended to evaluate or exclude, emphasizing serious conditions.)

Medical necessity rationale:

• [How the patient's presentation and objective data support the need for endoscopy]
• [What has been tried or evaluated and why it is insufficient to answer the clinical question]
• [Why endoscopy is indicated now rather than continued observation or alternative testing]
• [How endoscopy findings will change management: guide therapy, enable intervention, inform staging/surgical planning, adjust surveillance]

(Avoid vague phrases without anchors. Specify drug names, doses, durations, dates, values, and concrete next steps tied to potential findings.)

Urgency and Risk of Deferral

Urgency: [routine / expedited]

[If expedited: Time-sensitive clinical risk and expected impact of timely results. If routine: Brief statement that standard scheduling is appropriate.] (Keep brief for routine cases.)

Documents Submitted

• [Relevant clinic notes]
• [Laboratory reports: CBC, iron studies, H. pylori, stool tests]
• [Imaging reports]
• [Prior endoscopy and pathology reports]
• [Specialist consultation notes]

(List only documents actually submitted. For documents available but not attached, state: "Available upon request.")

Attestation and Contact

Ordering Clinician: [Name, credentials, NPI]

Servicing Endoscopist: [Name, credentials, NPI, facility name] (Include if different from ordering clinician.)

Peer-to-Peer Contact: [Name, phone, best callback times]

Signature: [Electronic signature block]