Prior Authorization Request (Nutrition Therapy Services)

Request Date: [YYYY-MM-DD]

Urgency Level: [Routine / Expedited]

Expedited Rationale: [Brief time-sensitive medical rationale] (Only include if Expedited)

Payer and Plan Name: [Payer name – Plan name]

Prior Authorization Reference #: [Reference number] (Only include if resubmission or appeal)

Patient Name: [First Last]

Date of Birth: [YYYY-MM-DD]

Member ID: [Member ID]

Group #: [Group number]

Rendering Provider: [Name, credentials] | NPI: [NPI]

Referring/Ordering Clinician: [Name, credentials] | NPI: [NPI]

Referral/Order Date: [YYYY-MM-DD]

Facility: [Facility name] | [Address] | Phone: [###-###-####] | Fax: [###-###-####]

Service Modality: [in-person / telehealth]

Services Requested

• Requested Codes:
  • [CPT/HCPCS code] – [Brief descriptor] | Units per visit: [#] | Unit basis: [15 / 30] minutes
  • [Additional CPT/HCPCS code] – [Brief descriptor] | Units per visit: [#] | Unit basis: [15 / 30] minutes (Include additional codes as needed)
• Visit Frequency: [# visits per week / month]
• Authorization Duration: [# weeks / months]
• Total Units or Visits Requested: [Total # units] and/or [Total # visits]
• Requested Start Date: [YYYY-MM-DD]
• Requested End Date: [YYYY-MM-DD]
• Place of Service: [POS code – description]
• Primary ICD-10-CM Diagnosis Code(s): [Code – description]; [Additional codes – descriptions] (Include only codes that directly support MNT)
• Request Exceeds Standard Plan Limits: [Yes / No] – Justification provided in Medical Necessity section (Only include if Yes)

Clinical Context and Nutrition Risk

Primary Diagnosis Driving MNT: [Diagnosis] | Diagnosis date: [YYYY-MM-DD / unknown]

Comorbidities Increasing Nutrition Complexity: [Relevant comorbidities with staging or severity] (Omit unrelated conditions)

Recent Clinical Events Affecting Nutrition Status: [Hospitalization / medication change / planned procedure / other] | Date: [YYYY-MM-DD] (Omit if none)

Risk Severity Summary: [Current nutrition status, trajectory, and consequence if untreated]

• Anthropometrics: Weight: [value, units] ([YYYY-MM-DD]); BMI: [value] ([YYYY-MM-DD]); Change: [±%] over [timeframe]
• Pertinent Labs: [Lab: value units (YYYY-MM-DD)]; [Lab: value units (YYYY-MM-DD)] (Include only labs relevant to the indication)
• Clinical Signs/Symptoms Impacting Intake or Absorption: [Signs/symptoms with onset dates and severity]
• Quantified Intake Deficits: [Estimated % energy needs met], [Estimated % protein needs met] over [# days/weeks] (Only include if documented)
• Malnutrition Criteria: [Assessment name] criteria met: [criteria]; Severity: [mild / moderate / severe]; Date: [YYYY-MM-DD] (Only include if applicable)
• Risk Tier: [high / moderate / standard]

Nutrition Diagnosis

• [Problem] related to [Etiology] as evidenced by [Signs/Symptoms with dated objective values]
• [Problem] related to [Etiology] as evidenced by [Signs/Symptoms with dated objective values] (Include 1–3 diagnoses that will be addressed during this episode)

Prior Interventions and Outcomes

• Prior Nutrition Management: (List most recent first)
  • [YYYY-MM-DD to YYYY-MM-DD]: [MNT visit / class / telehealth / written materials] by [Provider/role]; Frequency: [# visits, cadence]; Focus: [topics]
  • Outcomes: [Weight/lab/symptom changes with dates]; Adherence: [high / moderate / low]; Barriers: [documented barriers]
• No Prior Nutrition Intervention: [Statement explaining why skilled MNT is now indicated rather than less-intensive options] (Only include if no prior MNT occurred)

Proposed Treatment Plan and Goals

Structure: Initial comprehensive assessment [duration in minutes/units], then follow-up visits at [cadence] over [total authorization period].

Planned Interventions: [Nutrition education focus], [dietary prescription/meal planning], [behavioral counseling approach], [care coordination activities] (List only interventions relevant to stated problems)

Monitoring Plan: [Parameters to track between visits: weights, food logs, labs, symptoms, medication changes]

• Clinical Outcome Goals:
  • [Target with numeric value] by [timeframe]; Measurement: [lab / weight / vitals]
  • [Target with numeric value] by [timeframe]; Measurement: [method]
• Behavioral/Process Goals:
  • [Goal linked to PES diagnosis]: [quantified target] by [timeframe]; Measurement: [self-monitoring / 24-hr recall / other]
  • [Goal linked to PES diagnosis]: [quantified target] by [timeframe]; Measurement: [method]
  (At least one goal should address the signs/symptoms in each PES statement)

Medical Necessity Statement

[Narrative paragraph of 8–12 sentences establishing medical necessity] (Include: 1) Primary diagnosis and current nutrition-related risks with dated numeric data; 2) Why skilled MNT is required now, tied to disease stage, treatment changes, or clinical events; 3) Justification for requested frequency and duration based on clinical instability, diet complexity, and monitoring needs; 4) Why less-intensive options are insufficient, citing prior attempts or regimen complexity; 5) Likely clinical harms if services are delayed or denied; 6) If exceeding plan limits, explicitly state the change in condition warranting additional units with reference to ordering clinician's documentation)

Attachments Included

• [Signed referral/order dated YYYY-MM-DD]
• [Recent labs: list with dates]
• [Supporting clinic notes dated YYYY-MM-DD]
• [Malnutrition assessment dated YYYY-MM-DD] (If applicable)
• [Growth chart] (If pediatric)
• [Payer-required authorization form]
• [Pending: document name from source, requested YYYY-MM-DD] (If applicable)

Attestation

By signing below, I attest that the information provided is accurate to the best of my knowledge and derived from the medical record and patient report.

Signature: ________________________________ Date: [YYYY-MM-DD]

[Rendering clinician name, credentials]