Prior Authorization Request (Laboratory Test/Imaging)

Document Type: Prior Authorization Request – Laboratory Test/Imaging

Request Type: [Initial / Urgent/Expedited / Resubmission / Appeal Support] (If urgent, state why delay would be unsafe. For resubmission/appeal, reference prior denial reason and date.)

Payer/Plan: [Name of insurance plan or UM vendor]

Patient: [Full name], DOB: [MM/DD/YYYY], Member ID: [Member ID]

Ordering Provider: [Name, credentials], NPI: [NPI], Phone: [Phone], Fax: [Fax]

Servicing Facility/Lab: [Name], Address: [Address], NPI/TIN: [NPI/TIN if required]

Site of Service: [Outpatient / Inpatient / ED / Office / ASC / Other]

Anticipated Date of Service: [MM/DD/YYYY]

Prior Auth Case Number: [Case number or N/A] (Include only if resubmission or appeal.)

Executive Summary

[Reviewer-ready synopsis in 3–6 sentences: chief problem and duration; working diagnosis or clinical concern; key positive findings and relevant negatives; prior management and studies; exact test requested; how results will change management] (Use precise dates. Ensure consistency with all sections below.)

Requested Service

• Imaging: [Modality, body region with laterality, with/without contrast, sedation if needed, protocol details if relevant] – CPT/HCPCS: [Code(s)] (Include only for imaging requests.)
• Laboratory/Genetic Test: [Test name as performed by lab, methodology if relevant, specimen type, performing lab name] – CPT/HCPCS: [Code(s)], Payer test ID: [If required] (Include only for lab/genetic requests.)

Diagnoses and Indications

• Primary: [Diagnosis or indication] – ICD-10-CM: [Code]
• Secondary: [Relevant diagnoses/comorbidities affecting necessity] – ICD-10-CM: [Code(s)] (Include only if they materially support necessity.)
• Differential: [Diagnosis being ruled out] (Include only if directly supportive of request.)

Clinical Question

[Specific clinical question this test must answer] (One to three sentences. Must align with the requested service and diagnoses.)

Clinical Summary

• Symptoms:
  • [Onset date and total duration]
  • [Progression, severity, and frequency]
  • [Red flags or urgent features] (Include only if present.)
  • [Functional impact] (Include only if relevant to criteria.)
• Relevant History:
  • [Prior related diagnoses and pertinent comorbidities]
  • [Relevant surgical/procedural history]
  • [Medications affecting the test or safety]
  • [Family history/ancestry] (Include for genetic indications.)
  • [Pregnancy status] (Include if relevant to test safety.)
• Examination Findings:
  • [Pertinent positive findings]
  • [Key negative findings relevant to approval criteria]
  • [Focused neuro/MSK/phenotypic findings as applicable]
• Prior Testing and Results:
  • [MM/DD/YYYY] – [Test/Study] – [Key result and interpretation]
  • [MM/DD/YYYY] – [Test/Study] – [Key result and interpretation]
  • [External records requested MM/DD/YYYY; pending receipt] (Include if applicable.)

Conservative Management

(Include for outpatient advanced imaging, especially MSK/spine. Provide dates, durations, and responses for each intervention.)

• Physical therapy: [Start–End dates], [# sessions], Response: [Response]
• Home exercise/activity modification/bracing: [Start–Reassessment dates], Response: [Response]
• Medications: [Agent/class], [Duration with dates], Response: [Response or adverse effects]
• Injections/procedures: [Type], [MM/DD/YYYY], Response: [Response]
• Conservative therapy not performed: [Reason: contraindicated / red flags present / acute trauma / not required per policy] (Include only if conservative management was not attempted; must justify.)

Medical Necessity Rationale

• [Why the test is needed now: failure of initial management, progression, new deficit, staging, treatment selection]
• [Why lower-intensity alternatives are insufficient: prior nondiagnostic studies, clinical limitations]
• [Why the requested modality best addresses the clinical question for this patient]
• [Contrast justification and safety: renal function, allergy, pregnancy] (Include only if contrast requested.)
• [Guideline or payer policy alignment] (Include if known.)
• [Risk of delayed or denied testing] (Include if clinically significant.)

Expected Impact on Management

(Required. Map likely test outcomes to specific next steps. Avoid generic statements.)

• If [result A], then [management/action A].
• If [result B], then [management/action B].
• If [negative/incidental finding], then [contingency plan].

Safety and Special Requirements

(Include only elements relevant to the requested test.)

• Pregnancy status: [Status and precautions]
• Renal function: eGFR [Value] on [MM/DD/YYYY] (Required if IV contrast planned.)
• Contrast allergy: [History and premedication plan]
• MRI safety: [Implants/devices, claustrophobia, sedation plan]
• Genetic testing requirements: [Counseling/consent status, known familial variant, prior tumor testing]
• Other safety considerations: [Anticoagulation, isolation, pediatric needs]
• Items pending: [Elements to obtain prior to scheduling]

Attachments

(Include date for each document. Every clinical claim should be supported by an attachment.)

• Office visit note documenting symptoms and exam – [MM/DD/YYYY]
• Physical therapy notes or discharge summary – [Date range]
• Prior imaging or lab reports – [MM/DD/YYYY]
• Specialist consultation notes – [MM/DD/YYYY]
• Pathology/operative reports – [MM/DD/YYYY]
• Conservative treatment attestation or UM form – [MM/DD/YYYY]
• [Other supporting documentation] – [MM/DD/YYYY]

Provider Attestation and Contact

I attest that the information provided is accurate and supported by the medical record.

Ordering Clinician: [Name, credentials]   Date: [MM/DD/YYYY]

Peer-to-Peer Contact: [Direct callback number], Availability: [Days/times]

Preferred method for documentation requests: [Fax / Portal / Phone]

(If any payer-required field is unknown, enter "Unknown at time of request." Verify internal consistency among requested test, CPT/HCPCS codes, ICD-10 diagnoses, body part/laterality, and clinical question prior to submission.)