Prior Authorization Request (Enteral Formula)

Date: [Date of letter]

Payer: [Payer name]; Destination: [Fax number / Portal submission details]

Subject: Prior Authorization Request – Enteral Formula (Medical Necessity)

Patient: [Full name]; DOB: [DOB]; Member ID: [Member ID]; Address: [Street, City, State ZIP]

Ordering Clinician: [Clinician name, credentials]; NPI: [NPI]; Clinic: [Clinic name and address]; Phone: [Phone]; Fax: [Fax]

DME Supplier/Pharmacy: [Name, if known]

RE: [Formula name] – [Caloric density] kcal/mL, Route: [PO / NG / NJ / GT / GJ / JT], Daily Calories: [kcal/day], Requested Duration: [Duration]

Executive Summary

[Concise 4–6 sentence overview including: (1) primary diagnosis and specific pathophysiology impairing oral nutrition; (2) objective nutritional impact with dated weight/growth data; (3) standard strategies attempted and why inadequate or not tolerated; (4) exact request specifying formula name, caloric density, route, administration method, and whether sole-source vs supplemental; (5) requested duration and monitoring plan. Write so a reviewer can understand the entire request without reading further.]

Clinical Indication

• [Primary diagnosis (ICD-10 code)]
• [Secondary diagnosis affecting formula/route selection (ICD-10 code)] (Add additional diagnoses as applicable)
• [Device/access diagnosis if applicable (ICD-10 code)]

[Narrative linking diagnosis → functional impairment → inability to maintain adequate nutrition/hydration. State whether the GI tract is functional and accessible; explain why oral diet alone is inadequate (e.g., mechanical, neurologic, absorptive, behavioral with medical compromise). Cite confirming studies by type and date when available (e.g., swallow study, endoscopy, stool/malabsorption testing, imaging). If no studies were performed, state "Not performed."]

Nutrition Status and Impact

Anthropometrics:

• (Pediatric patients) Weight with dates: [Weight (date), weight (date), weight (date)]; Length/Height: [Value (date)]; BMI-for-age or weight-for-length: [Percentile, z-score (date)]; Growth velocity and percentile crossing: [Description (date range)]; Head circumference (infants): [Value (date)]
• (Adult patients) Current weight: [Weight (date)]; Prior weights: [Weight (date), weight (date)]; Percent unintentional weight change: [Percent over timeframe]; BMI: [Value]; Physical findings of malnutrition: [Muscle/fat loss, edema, functional status] (Only include if documented)

Intake adequacy and needs:

• Estimated needs: [kcal/day], [protein g/day], [fluid mL/day]; Calculation method: [kcal/kg / predictive equation / clinical standard]
• Current intake: [kcal/day], [protein g/day] or [percent of estimated needs]; [Description of variability if applicable]

Symptoms/complications related to inadequate intake or intolerance: [Fatigue / activity intolerance / delayed healing / dehydration / electrolyte abnormalities / aspiration pneumonia / vomiting / diarrhea / steatorrhea / prolonged or unsafe feeding times / other] (Only include if documented)

Failed Standard Strategies

(Document each relevant intervention. When requesting a specialty formula, clearly establish why standard formula is not appropriate.)

• Intervention: [Description]; Date range: [Dates]; Dose/Approach: [Details]; Outcome: [Objective data: weight change, symptoms, tolerance]; Reason insufficient: [Reason]
• Intervention: [Description]; Date range: [Dates]; Dose/Approach: [Details]; Outcome: [Objective data]; Reason insufficient: [Reason]

(Add additional interventions as needed)

Requested Enteral Formula and Regimen

Formula: [Formula name]; Category: [standard polymeric / semi-elemental / elemental / disease-specific]; Caloric density: [kcal/mL]; Key features: [Fiber content, MCT %, electrolyte profile, carbohydrate modification] (Include only if clinically critical)

Daily regimen: Total daily volume: [mL/day]; Total daily calories: [kcal/day]; Total daily protein: [g/day]; Free water plan: [Flush volume/frequency for tube-fed or oral fluids plan]; Nutrition role: [sole-source / supplemental (~percent of needs)]; Container size and monthly quantity: [Container volume and number per month]

Rationale for formula selection: [Explanation of why standard formula is not appropriate, explicitly connecting prior trial outcomes to the requested formula's features. Address malabsorption, documented intolerance, volume restriction, metabolic requirement, or allergy/medical need.]

Route and Administration

Route: [PO / NG / NJ / GT / GJ / JT]; Device type: [Tube type/model]; Placement date: [Date]; Access considerations: [e.g., jejunal feeds required due to gastric intolerance or aspiration risk]

Administration method: [Bolus / Continuous / Cyclic]; Schedule: [Daytime / nocturnal / combination with start–stop times]; Delivery: [Gravity / Pump]; Maximum rate: [mL/hr] (Include for tube-fed patients)

Pump justification: [Clinical indication such as aspiration risk with faster delivery, need for controlled slow rate below 100 mL/hr, jejunal feeding requirement, glycemic instability, or fluid sensitivity] (Include only if requesting pump; do not justify for convenience alone)

Monitoring and Follow-up Plan

• Clinical monitoring: Weight: [Frequency]; Intake records: [Frequency]; Stool/emesis tracking: [Method]; Hydration status: [Parameters]; Aspiration signs: [Monitoring plan] (if applicable)
• Device monitoring: Stoma/skin integrity: [Frequency]; Leakage/clogging management: [Plan] (Include for tube-fed patients)
• Laboratory monitoring: [Electrolytes, renal function, glucose, micronutrients] at [Interval] (Include if indicated, especially for long-term or exclusive enteral feeding)
• Refeeding risk management: Risk status: [High / moderate / low]; Initiation/advancement plan: [Details]; Lab monitoring: [Frequency] (Include only if applicable)
• Tolerance management: [Planned responses to diarrhea, constipation, vomiting, or tube complications with stepwise adjustments]
• Follow-up: Next reassessment: [Date or interval]; Criteria for escalation/de-escalation: [Transition to standard formula, rate adjustment, or discontinuation when oral intake meets goals]

Duration and Reauthorization

Requested authorization duration: [Timeframe]. Expected course: [Temporary with recovery milestone / long-term or indefinite] with rationale: [Supporting statement]. Reauthorization plan: At renewal, will provide [Updated weights/growth charts, intake/tolerance data, lab results, device status, and outcomes]. Clinical consequences of supply interruption: [Risk of weight loss, dehydration, hospitalization, aspiration, growth failure]

Supporting Documentation Attached

• Recent clinic notes: [Dates]
• Registered Dietitian assessment: [Date]
• Growth charts or weight trend table: [Date range]
• Swallow study report: [Date] (if performed)
• GI studies and lab results: [Test type and dates]
• Hospital discharge summary: [Date] (if EN initiated inpatient)
• Prior formula trial documentation: [Dates/products/approaches]
• Other relevant records: [List] (State "available upon request" only if retrievable but not attached)

Signature

Sincerely,

[Treating clinician signature] ____________________________ Date: [Date]

Printed Name/Credentials: [Name, credentials]   NPI: [NPI]

Registered Dietitian: [Name, credentials] (Include if co-authoring nutrition regimen)

Direct callback number for peer-to-peer: [Phone]; Availability: [Days/times]