Prior Authorization Request (Medication, Pediatric Nephrology)

Date: [Submission date]

Document Type: Prior Authorization Request – Medication (Pediatric Nephrology)

Urgency: [Routine / Expedited] (If expedited, include brief reason)

Payer/Plan: [Payer name and plan]

Fax/Portal: [Fax number or portal submission reference]

Patient: [Full name]

DOB: [Date of birth]

Member ID: [Member ID]

Group Number: [Group number] (Omit if not applicable)

Weight: [Weight in kg] (measured [Date]) (Required for weight-based dosing)

Requested Medication: [Brand name (generic name)], [formulation/route]

Diagnosis/Indication: [Clinical diagnosis] (ICD-10: [Code])

Requesting Clinician: [Name, credentials, subspecialty]

NPI: [NPI]

Practice: [Practice name and address]

Contact: [Phone] | [Fax] | [Best callback times for peer-to-peer]

Revised on: [Date of revision] — [Brief description of changes] (Include only if this is a revision of a prior submission)

Purpose Statement

I am requesting prior authorization for [Requested medication] for [Patient name] for treatment of [Indication] due to [Brief clinical rationale summarizing necessity].

Executive Summary

[Diagnosis and explicit subtype/classification with supporting data. Key objective severity markers with dates. Concise summary of prior therapies and outcomes. Why the requested therapy is needed now and risks of delay. Brief monitoring plan.] (Write as one paragraph of approximately 5–8 sentences. Use specific data and dates rather than adjectives.)

Diagnoses and Codes

Primary Diagnosis: [Clinical label] (ICD-10: [Code])

Secondary Diagnoses: [Relevant comorbidities with ICD-10 codes; e.g., CKD stage, hypertension, thrombosis history, infection risk factors] (Write "None" if none)

Requested Drug: [Name], [dose] [route], [schedule] (Show weight-based calculation if applicable: [mg/kg] × [weight kg] = [total dose])

Authorization Period Requested: [Duration] with [reassessment plan]

Billing Codes: [HCPCS/CPT and site of care] (Write "Not applicable" or "Code not available" if unknown)

Diagnostic Evidence

The patient meets criteria for [Condition/subtype] as evidenced by the following. (Do not apply labels such as steroid-resistant, frequently relapsing, or complement-mediated TMA without stating the defining criteria and supporting data.)

• Nephrotic syndrome (Include only if relevant to indication)
  • [Urine protein-to-creatinine ratio or 24-hour protein: value, units, date]
  • [Serum albumin: value, units, date]
  • [Edema course: objective description with dates]
  • [Kidney biopsy findings and date, if performed] (Write "Not obtained," "Not indicated," "Pending," or "Unavailable from outside records" if applicable)
  • [Genetic testing status and results, if relevant]
• Complement inhibitor indications (Include only if relevant)
  • [Platelet count: value, units, date]
  • [Hemoglobin: value, units, date]
  • [LDH: value, units, date]
  • [Haptoglobin: value, units, date]
  • [Creatinine/eGFR: value, units, date]
  • [Complement studies: test, value, units, date] (if available)
  • [Documentation of excluded alternative diagnoses with dates and sources]
• CKD anemia (Include only if relevant)
  • [Hemoglobin trend with dates]
  • [Ferritin: value, units, date] | [TSAT: value, units, date]
  • [CKD stage and dialysis status]
  • [Evaluation of reversible causes with results and dates]

(For data from external sources, label as "Per [source] dated [date]." For unavailable data, state "Not obtained," "Not indicated," "Pending," or "Unavailable from outside records.")

Clinical Course Timeline

• [Date]: [Initial diagnosis and baseline severity]
• [Date]: [Key relapse or hospitalization with objective findings]
• [Date]: [Complications: AKI, thrombosis, infections, growth suppression, steroid toxicity, transfusions]
• [Date]: [Most recent event prompting current request]

(For new-onset disease with minimal history, use a brief 2–4 item list focusing on diagnosis date, current severity, and precipitating reason for therapy.)

Prior and Current Therapies

• [Medication name]: [Dose and route], [Start date] to [Stop date / ongoing]
  • Objective response: [Measured outcomes with dates]
  • Intolerance/toxicity: [Specific adverse effects with dates] (Omit if none observed)
  • Reason discontinued/insufficient: [No remission / Relapse during taper / Inadequate lab response / Adverse effects / Contraindicated]

(Repeat for each prior therapy relevant to step therapy. Do not claim "failure" without stating the outcome that defined failure.)

Steroid exposure summary (Include for steroid-sparing requests): [Number of courses], [Cumulative duration], [Toxicity signals with objective data and dates: behavioral changes, growth suppression with percentiles, obesity with BMI, hypertension with BP, cataracts, glucose intolerance, bone effects].

(If prior therapy details are incomplete, document what is known and state that additional records have been requested.)

Rationale for Requested Medication

Medical necessity and intent: [Plain-language mechanism and therapeutic goal]

Patient-specific need: [Risk being mitigated with objective data and dates]

Why alternatives are inadequate: [Failed / Contraindicated / Not appropriate], with [brief data and dates]

Consequences of delay/denial: [Hospitalization risk / Progressive kidney injury / Transfusion dependence / Severe steroid toxicity], with [supporting data]

Off-label use: [Clinical rationale], [Why on-label options are unsuitable], [Monitoring and stopping rules], [Supporting evidence or guideline reference] (Include only if off-label)

Safety and Monitoring Plan

Baseline (completed or planned): [Vitals including blood pressure], [Growth parameters], [CBC with differential], [CMP with albumin], [Urinalysis], [Infection screening], [Vaccination review] (Include dates for completed items; omit items not applicable to indication)

Ongoing monitoring: [Lab monitoring cadence], [Clinical monitoring parameters], [Response criteria defining success], [Stopping rules or triggers for discontinuation/escalation]

Complement inhibitor requirements: [Meningococcal vaccination status (MenACWY and MenB) with dates], [Antibiotic prophylaxis plan if urgent initiation precedes vaccination], [Patient/family education on meningococcal symptoms and emergency plan completed], [REMS enrollment status] (Include only for complement inhibitors. If vaccine records are incomplete, document that records have been requested and state the interim plan.)

Request and Attachments

Please approve [Drug name] at [Dose] [Route] [Schedule] for [Duration] for [Diagnosis]. (If applicable, include associated necessities: infusion administration, monitoring labs, required prophylaxis.)

Peer-to-peer: If further review is needed, please contact [Clinician name] at [Phone] during [Best callback times].

Attachments:

1. Recent clinic note(s)
2. Key laboratory results with dates
3. Pathology or biopsy report (if applicable)
4. Genetic or complement testing (if applicable)
5. Growth chart or steroid toxicity documentation (if relevant)
6. Hospital discharge summary (if relevant)

(If any referenced attachment is not included, state why and when it will be sent.)

Signature

Signature: [Electronic signature]

Printed Name and Credentials: [Name, credentials]

Subspecialty: Pediatric Nephrology

NPI: [NPI]

Date Signed: [Date]