Prior Authorization Request (Ophthalmic Medication/Diagnostic Test)

Document Title: Prior Authorization Request – Ophthalmic Medication/Diagnostic Test

Date Created: [Date of submission]

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

Patient: [Full name], DOB: [Date of birth], Member ID: [Plan member ID], Plan: [Payer plan name]

Request Tracking: Prior Auth Ref # [Reference number if known] | Submission Method: [ePA portal / web form / fax / phone]

Requesting Clinician: [Clinician name], [Credentials] | NPI: [NPI] | Practice: [Practice name] | Address: [Full address] | Phone: [Number] | Fax: [Number]

Rendering Site-of-Care: [Facility name and full address] (Only include if site-of-care differs from requesting clinician's office)

Decision Summary

Requested Item

• Medication Request (Only include if requesting a drug; otherwise omit this subsection)
  • Medication: [Generic name] ([Brand name])
  • Formulation/Route: [Formulation and route of administration]
  • Strength and Dosing: [Strength], [Dose and frequency]; Loading dose: [If applicable]
  • Quantity (pharmacy benefit): [Quantity] for [Days' supply]
  • Units (medical benefit): [Units or vials per dose] every [Interval]
  • Billing Code(s): NDC: [If available] | HCPCS: [J-code if available]
  • Benefit Type: [Pharmacy / Medical]
  • Duration of Therapy Requested: [Duration]
• Diagnostic Test Request (Only include if requesting a test; otherwise omit this subsection)
  • Test: [Test name]
  • CPT Code: [Code if available]
  • Laterality: [OD / OS / OU]
  • Frequency/Interval Requested: [Frequency]
  • Clinical Purpose: [Decision the test will inform]

Diagnosis and Severity

• Diagnosis: [Diagnosis name] | ICD-10-CM: [Code]
• Laterality/Stage: [OD / OS / OU]; [Stage if applicable]
• Severity Anchors: [Relevant objective measures with dates, such as BCVA, IOP, cup-to-disc ratio, RNFL thickness, visual field MD/PSD with reliability, OCT CST/fluid status, hemorrhages/exudates] (Include only anchors relevant to this request)
• Current Status/Trajectory: [stable / worsening / vision threatened], supported by [objective metrics with dates]

Prior Therapies and Step Therapy Outcomes

(Include only when payer criteria reference step therapy or prior treatment failure; otherwise omit this subsection)

• [Therapy name] – Dates: [Start–End or ongoing]. Outcome: [ineffective / partial response / intolerant / contraindicated / not accessible]. Details: [Objective response data or adverse effects; reason therapy cannot continue].
• (Repeat for each relevant prior therapy. Use "failed" only for inadequate response after adequate trial or inability to continue due to adverse effects; use "not accessible" for cost or formulary barriers.)

Medical Necessity Statement

• Clinical risk if not approved: [Specific risk]
• Rationale for requested option: [Why expected to work based on disease mechanism, prior response, or guideline-supported use]
• Why alternatives are unsuitable: [Ineffective / intolerant / contraindicated / not accessible] with brief justification
• Success metrics: [Objective targets and monitoring plan]

Attachments Included

[List of attached documents with dates] (Reference detailed checklist at end of document)

Clinical Context

[Brief narrative of disease onset and course, laterality, key symptoms and functional limitations, prior relevant ocular procedures. Include ocular or systemic comorbidities only if they affect coverage, safety, or medical necessity.] (1–3 concise sentences; omit unrelated history)

Supporting Objective Findings

• Exam Findings (Date: [Exam date])
  • Visual Acuity: [BCVA with correction status] [OD/OS]
  • IOP: [Value and method] [OD/OS]
  • Pertinent Findings: [Optic nerve, macular, retinal, or anterior segment findings relevant to request]
• Diagnostic Testing Already Performed (Include only tests with results that support this request)
  • [Test name and laterality] ([Date]): [Key quantitative and qualitative results]; Reliability: [If applicable]; Interpretation: [One-line impact on management]
• For Requested Diagnostic Test (Include only if this request is for a test)
  • Clinical question: [What remains unanswered]
  • Decision impact: [What treatment, interval, or diagnosis will be determined by results]
  • Why alternatives are insufficient: [Brief justification] (Avoid framing as screening unless benefit explicitly covers screening)

Medical Necessity Rationale

• Therapeutic goal: [Preserve vision / achieve target IOP / reduce macular edema / confirm diagnosis / guide treatment interval]
• Success metrics: [Specific objective thresholds and timeframe]
• Appropriateness of requested item: [Mechanism-level rationale and patient-specific factors such as severity, progression despite standard care, or inability to rely on alternatives]
• Alternatives addressed: [Ineffective / intolerant / contraindicated / not accessible] with concise supporting facts
• Safety/Monitoring: [Adverse event monitoring plan and contraindication checks] (Include for higher-risk medications)
• Off-label use: [Yes / No]. If yes: [Concise clinical justification; note if supporting literature attached per payer requirement]

Urgency and Risk of Delay

(Include this section only if clinically urgent; omit entirely if routine)

• [Concrete harm risk if delayed]
• [Time sensitivity with specific date or timeframe if applicable]

Duration and Follow-up Plan

• Medication (Include only if requesting a medication)
  • Planned duration: [Authorization period requested] with reassessment at [interval]
  • Continuation criteria: [Objective success metrics and tolerability]
  • Discontinuation/De-escalation criteria: [Objective triggers]
  • Follow-up: [Clinic visit and testing cadence]
• Diagnostic Test (Include only if requesting a test)
  • Timing: [Scheduled or anticipated date]
  • Management linkage: [How results will change treatment or interval]
  • Repeat interval: [Frequency if series requested]

Attachments Checklist

• Most recent ophthalmology clinic note: [Included / Not included – reason]
• OCT reports with interpretation: [Included / Not included – reason]
• Visual field printouts with interpretation: [Included / Not included – reason]
• Fundus photographs with interpretation: [Included / Not included – reason]
• Medication history or fill records: [Included / Not included – reason]
• Adverse reaction documentation: [Included / Not included – reason] (Required if intolerance claimed)
• Prior denial letter(s) and appeal points: [Included / Not included – reason] (If applicable)
• Payer's prior authorization form: [Included / Not included – reason] (If required by payer)

(If an expected attachment is unavailable, state reason and reference alternative supporting documentation)

Attestation and Signature

I attest that I am the treating provider for this patient and that the requested medication/diagnostic test is medically necessary for the diagnosis, treatment, or management of the stated condition.

Signature: ____________________________________

Printed Name/Credentials: [Name, Credentials] | Date/Time: [Date and time]

Peer-to-Peer Contact: Direct line: [Phone number]; Best availability: [Days and times]