Prior Authorization Request (Genetic Test)

(Do not leave any required field blank. If information is unavailable, enter "Unknown," "Not obtained," "Not applicable," or "Pending" with a brief explanation.)

Document Title: Prior Authorization Request (Genetic Test)

Date of Submission: [Date of submission]

Request Type: [Standard / Expedited / Urgent] (If Expedited or Urgent, include clinical justification.)

Internal Tracking ID: [Internal tracking ID]

Payer Name: [Payer name]

Plan/Product: [Plan or product name]

Member ID: [Member ID]

Group ID: [Group ID]

PA Reference Number: [PA reference number / Not yet initiated]

Patient Name: [Patient full name]

Date of Birth: [Date of birth]

MRN: [Medical record number]

Current Status: [Outpatient / Inpatient / Prenatal] (If prenatal, include gestational age.)

Ordering Clinician: [Name and credentials]

Specialty: [Specialty]

NPI: [NPI]

Practice Name and Address: [Practice name and full address]

Peer-to-Peer Contact: [Phone and fax with best call windows]

Performing Laboratory: [Laboratory name / Unknown]

Laboratory Address: [Address / Unknown]

CLIA Number: [CLIA number / Unknown]

Executive Summary

Clinical Question: [One sentence stating diagnostic question and how result will change management]

Key Clinical Features: (Include 3–6 criterion-relevant findings with dates or ages of onset.)

• [Phenotypic feature with objective detail and date or age of onset]
• [Phenotypic feature with objective detail and date or age of onset]
• [Phenotypic feature with objective detail and date or age of onset]

Prior Workup Summary: (Include 2–6 key evaluations with results and dates.)

• [Evaluation or test, result, and date]
• [Evaluation or test, result, and date]
• [Evaluation or test, result, and date]

Test Requested: [Test name and type] (State why this test rather than narrower or alternative methods.)

Coverage Conclusion: [One sentence indicating criteria appear met, referencing the policy and Mapping Table below]

Management Impact Preview: (Include 2–5 anticipated management actions contingent on results.)

• [Management action tied to a positive result]
• [Management action tied to a negative result]
• [Management action tied to a VUS]

Requested Test Details

Test Name (as marketed/ordered)	[Test name]
Test Category	[Single-gene / Targeted variant / Panel / Exome / Genome / Tumor / Pharmacogenomic]
Intended Use	[Diagnostic / Predictive / Carrier / Prenatal / Somatic]
Genes/Regions Analyzed	[Gene or region list / See attached gene list]
Variant Types Detected	[SNVs / Indels / CNVs / Repeat expansions / Mitochondrial] (Note known test limitations.)
Specimen Type	[Blood / Saliva / Amniotic fluid / CVS / Tumor tissue / Other]
Trio/Duo/Singleton	[Singleton / Duo / Trio] (If duo or trio, list individuals and relationships.)
Expected Turnaround Time	[Turnaround time]

Billing Codes (CPT/HCPCS): [Codes / Pending lab finalization]

ICD-10-CM Codes: [Relevant diagnosis codes for indication]

Test Selection Rationale:

• [Why this test matches the phenotype and differential diagnosis]
• [Why narrower testing is insufficient or already performed]
• [If broad testing requested, why breadth is necessary]

Clinical Indication

[Concise indication statement: suspected or established diagnosis and why genetic testing is needed now]

Phenotype and Clinical Features: (Include 5–15 positive findings with objective details. Include key negatives only if they narrow the differential or are required by payer criteria.)

• [Finding with measurement, date, severity, and functional impact]
• [Finding with measurement, date, severity, and functional impact]
• [Finding with measurement, date, severity, and functional impact]

Specialty-Specific Details: (Include only the applicable category below; omit others.)

• Hereditary cancer: [Personal cancer history with type, age at diagnosis, pathology markers, prior tumor testing, prior germline testing]
• Prenatal: [Gestational age, fetal imaging findings, prior prenatal genetic testing results]
• Neurodevelopmental: [Developmental milestones, regression, neurologic findings, metabolic screening, brain imaging]

(If phenotype is incompletely characterized, state the limitation and emphasize available objective findings.)

Family History

Pedigree: [Three-generation pedigree obtained / Not obtained] (If not obtained, explain: adoption, unavailable informants, emergent context.)

Consanguinity: [Present / Denied / Unknown]

(Include table only if family history is relevant to coverage criteria or suspected condition. If non-contributory and not required, state "No relevant family history known" and omit table.)

Relationship	Condition	Age at Diagnosis	Confirmatory Details
[Relationship]	[Condition]	[Age]	[Pathology or genetic confirmation if known]
[Relationship]	[Condition]	[Age]	[Pathology or genetic confirmation if known]

Family History Summary: [One sentence stating whether the pattern supports the suspected condition]

Prior Workup and Testing

(List in reverse chronological order with dates.)

• [Date] — [Specialist evaluation or test]: [Key findings and results]
• [Date] — [Genetic test name, lab, scope]: [Result and notable limitations]
• [Date] — [Additional relevant workup]: [Results]

(If prior genetic test reports are unavailable, state where testing occurred, approximate date, and efforts to obtain records.)

Rationale for Additional Testing: [Why further testing is needed: limited prior scope, older methods, evolved phenotype, need to assess different variant types]

Coverage Criteria Mapping

Payer Policy Referenced: [Policy name, number, version or effective date, and applicable test category]

Criterion	Patient Evidence	Source Document	Status	Comments
[Policy criterion verbatim or close paraphrase]	[Evidence with dates]	[Note, report, or attachment label]	[Met / Not Met / Not Applicable / Unknown]	[Clarification or remediation plan]
[Policy criterion]	[Evidence with dates]	[Source document]	[Met / Not Met / Not Applicable / Unknown]	[Clarification or remediation plan]

(Add additional rows as needed, following the order criteria appear in the payer policy. Do not claim a criterion is met without documented evidence.)

Medical Necessity Narrative:

[1–2 paragraphs synthesizing the mapping: why the presentation fits covered indications, why the selected test is reasonable and necessary versus alternatives, and how results will be actively used in management]

Anticipated Clinical Utility

If Pathogenic/Likely Pathogenic:

• [Specific surveillance protocol with modality and interval]
• [Treatment eligibility or targeted therapy consideration]
• [Procedures or medications to avoid or modify]
• [Cascade testing plan for at-risk relatives]

If Negative/No Diagnostic Variant:

• [Clinical monitoring plan and interval]
• [Alternative diagnoses or additional testing to consider]
• [Reanalysis timeframe if applicable]

If Variant of Uncertain Significance:

• [Segregation or functional studies if applicable]
• [Periodic reanalysis timeline]
• [Clinical management unchanged pending reclassification]

Genetic Counseling and Consent

(Include when required by payer or test type, or if counseling was performed.)

Pre-test Counseling: [Date, counselor or clinician name and credentials]

Topics Covered: [Purpose and limitations, result types, secondary findings approach, familial implications, post-test plan]

Consent Status: [Informed consent obtained / Pending] (If pending, state plan and timeline.)

Secondary Findings Choice: [Opt-in / Opt-out / Not applicable]

Attachments

(Each item referenced in the Mapping Table must be attached or explained as unavailable.)

• Genetics clinic note or ordering provider note: [Attached / Pending / Not available]
• Three-generation pedigree or family history summary: [Attached / Pending / Not available]
• Key imaging reports: [Attached / Pending / Not available]
• Pertinent lab and pathology reports: [Attached / Pending / Not available]
• Prior genetic test reports: [Attached / Pending / Not available]
• Test requisition and gene list: [Attached / Pending / Not available]
• Counseling and consent documentation: [Attached / Pending / Not available]

Attestation and Signature

The ordering clinician is treating the patient for this condition and will use the genetic test results in management decisions.

The submitted information is accurate and complete to the best of the submitter's knowledge.

The requested test is expected to meet medical necessity criteria as documented herein.

Ordering Clinician Signature: [Signature]

Credentials: [Credentials]

Date/Time: [Signature date and time]

Last Updated: [Timestamp]