Prior Authorization Request (Imaging/DME)

Prior Authorization Request

(Payer-facing document to demonstrate medical necessity. Use "REQUIRED—UNKNOWN" for any administratively required field not available at authoring time. Omit sections not applicable to the request type or current submission.)

Patient & Coverage

• Patient: [Full legal name]
• DOB: [Date of birth]
• Sex: [Sex per payer record]
• Member ID: [Member ID]
• Group ID: [Group ID] (Omit if not applicable)
• Payer: [Insurance company and plan type]

Ordering Clinician & Servicing Entity

• Ordering Clinician: [Name and credentials]
• NPI: [Clinician NPI]
• Clinic/Practice: [Practice name]
• Phone/Fax: [Contact for payer follow-up]
• Servicing Entity: [Imaging facility name or DME supplier name]
• Servicing NPI: [Facility or supplier NPI] (Omit if not applicable or unknown)

Urgency

Urgency: [Standard / Expedited] (If expedited, include brief justification tied to clinical risk, deterioration, or time-sensitive care.)

Request Summary

• Request Type: [Advanced Imaging / DME-Orthoses]
• Requested Service: [CPT or HCPCS code], [Body region or device name], [Laterality], [Quantity]
• Target Diagnosis: [Diagnosis name] — [ICD-10 code]

Medical Necessity Thesis: [Single sentence linking diagnosis, objective concern, and why service is needed now]

Clinical Indication

Primary Working Diagnosis: [Diagnosis name and ICD-10 code]

• Key Differentials: [2–5 differentials the request aims to confirm or exclude]
• Symptom Timeline: [Onset date or estimate], [Mechanism: injury / insidious], [Duration and course], [Severity with functional impact on ADLs, work, gait, or sleep]
• Red Flags: [Red flag findings with supporting details] (Omit this line if no red flags present)

(Do not characterize symptoms as "severe" or "progressive" without specific qualifying details.)

Objective Findings

• Physical Examination: [Pertinent findings with laterality, relevant special tests, and neurovascular status if applicable]
• Prior Diagnostics:
  • [Test type], [Body part], [Date], [Key result or impression], [How result informs current request]
  • (Repeat for each prior diagnostic. Include only completed tests with results.)
• Relevant Labs: [Lab name, date, result, and rationale for inclusion] (Omit if not clinically pertinent)

Conservative Management Attempted

(Document each therapy with dates, duration, adherence, response, and reason stopped or ongoing. Do not state "failed conservative therapy" without these details.)

• Therapy: [Name or type of therapy]
  • Dates/Duration: [Start date – End date], [Number of visits or weeks]
  • Adherence: [Good / Partial / Poor] with [objective detail such as visit count or usage logs]
  • Response: [Quantified change in pain or function]
  • Reason Stopped or Ongoing: [Reason including intolerance, plateau, adverse effects, or continuation]
• (Repeat for each therapy modality: medications, PT/OT, HEP, bracing, injections, activity modification, work restrictions, etc.)
• If No Conservative Therapy: [Explicit justification: contraindication, red flags requiring urgent evaluation, intolerance, safety risk, or payer-defined exception] (Omit if therapies were attempted)

Imaging Request Details

(Include only if Request Type is Advanced Imaging.)

• Modality: [MRI / CT] — [without contrast / with contrast / with and without contrast] (Include brief rationale if contrast requested)
• Body Part & Laterality: [Region and side]
• Special Considerations: [Sedation, metal implants, renal function, pregnancy, device compatibility] (Omit if none)
• Specific Clinical Question: [Question the imaging must answer]
• Why Imaging Is Needed Now: [Triggering factor: persistent symptoms beyond expected timeframe with dates, inadequate response to conservative care with dates and outcomes, objective deficits, pre-operative planning, or concern for serious pathology]
• Impact on Management: [Explicit next steps contingent on results: if positive then X, if negative then Y]
• Comparison Studies: [Prior relevant imaging with dates] (Omit if none)
• CPT Code(s): [CPT code(s)]

DME/Orthoses Request Details

(Include only if Request Type is DME-Orthoses.)

• Item Category: [Walking boot / Knee brace / Lumbar orthosis / Foot orthotic / Other]
• HCPCS Code(s): [HCPCS code(s)]
• Laterality and Quantity: [Left / Right / Bilateral], [Quantity]
• Type: [Off-the-shelf / Custom-fitted / Custom-fabricated]
• Sizing/Measurements: [Measurements or sizing details] (Omit if not applicable)
• Functional/Therapeutic Goals: [Immobilization / Stabilization / Offloading / Deformity prevention / Pain reduction / Gait safety / Post-op protection]
• Patient Functional Status: [Ambulatory status, fall risk, ability to don and doff, caregiver support, skin integrity concerns]
• Face-to-Face Encounter: [Date of qualifying encounter] (Include only if required by payer or program)
• Estimated Duration of Need: [Duration]

Medical Necessity Narrative

[5–10 sentence synthesis addressing: diagnosis and functional impact; objective evidence supporting diagnosis or concern; conservative care attempted with dates, adherence, and outcomes; why requested service is indicated now; how result or device will change management; risk of deferral or non-approval] (Ensure all statements are supported by details documented above.)

Referenced Documentation

(Include only if attachments are submitted or expected.)

• Office/ED Notes: [Date(s)]
• PT/OT Notes: [Date range] (Enter PENDING with expected date if not yet available)
• Prior Imaging Reports: [Modality and date(s)]
• Operative Reports: [Procedure and date(s)] (Omit if not applicable)
• Payer-Specific Forms: [Form name and date]

Prior Authorization History

(Include only for resubmissions or appeals.)

• Prior Submission Date(s): [Date(s)]
• Denial Reason(s): [Verbatim denial language when available]
• New Information in This Submission: [Summary of new clinical data, updated exams, new imaging, therapy adherence details]
• Peer-to-Peer Review: [Requested / Completed on date / Outcome] (Omit if not applicable)

Authentication

• Signature: [Ordering clinician electronic signature]
• Date/Time Signed: [Date and time]
• Credentials: [Clinician credentials]