Prior Authorization Request (PET/CT)

Prior Authorization Request: PET/CT (Oncologic Indication)

(This is a payer-facing medical necessity document. Use only objective, necessity-supporting facts. For any required field not available, enter "REQUIRED FOR AUTHORIZATION.")

Administrative Header

Patient: [Name] | [DOB] | [MRN] | [Payer member ID or "REQUIRED BEFORE SUBMISSION"]

Ordering Clinician: [Name] | [Specialty] | [NPI]

Facility: [Facility name] | [NPI]

Requested Exam: [Exam name] | [Anatomic coverage] | [Diagnostic CT with IV contrast: yes/no]

Authorization Diagnosis: [ICD-10 code(s)] — [Plain-language diagnosis] (If multiple malignancies exist, specify which is being evaluated.)

Requested Timing: [Desired scan date window] | [Urgency: routine / urgent / expedited] — [Brief reason if urgent]

Medical Necessity Summary

[Narrative summary, 3–6 sentences] (Cover in order: 1) Diagnosis and current status—newly diagnosed, post-treatment, suspected recurrence, or interim assessment; 2) Specific clinical question PET/CT must answer; 3) Why conventional imaging is insufficient; 4) Concrete management decision that will change based on PET/CT findings; 5) Why timing is appropriate. Include explicit statement that this is not routine surveillance if applicable, noting the objective trigger. If a concrete management-change statement cannot be articulated, obtain clarification before submission.)

Clinical Context

• Primary site and histology: [Anatomic primary] — [Histology/subtype]
• Date of diagnosis: [Date] — [Diagnostic basis: pathology/cytology]
• Current status category: [initial staging / end-of-treatment restaging / suspected recurrence / interim response assessment (cycle #) / treatment planning]
• Stage: [Documented stage or "staging pending"]
• Symptoms or findings prompting request: [Signs, symptoms, or objective triggers with attribution]
• Performance status: [ECOG/KPS] (Include only if it affects surgical candidacy or treatment eligibility; otherwise omit.)

Prior Imaging and Diagnostic Work-up

(List relevant studies in reverse chronological order. Include tumor markers only if they triggered this request.)

• [Date — Modality and body region]: [Key impression with attribution]. [Why insufficient: equivocal / discordant / limited sensitivity].
• [Date — Modality and body region]: [Key impression]. [Why insufficient]. (If report unavailable, note location where study was performed.)
• [No prior PET/CT for this diagnosis / Prior PET/CT on (date) informed: (management decision)]
• Tumor markers (if applicable): [Marker]: [Value and trend with dates]

Treatment History

(Include only treatments relevant to timing rationale. Omit categories that do not apply.)

• Surgery: [Procedure] — [Date]
• Radiation: [Site] — [Completion date]
• Systemic therapy: [Regimen] — [Last dose date] | [Cycle count if interim assessment]
• Next planned step dependent on PET/CT: [Specific management decision requiring these results]

Decision Impact Statement

(Provide 2–5 conditional pathways mapping PET/CT findings to concrete actions. Avoid vague statements like "guide treatment." If pathways are not documented, obtain clarification before submission.)

• If [specific PET/CT finding], then [concrete clinical action with target date if applicable].
• If [alternative PET/CT finding], then [alternative clinical action].
• If [third scenario], then [corresponding management change].

Timing Rationale

• Interval since surgery: [Duration since date, or N/A]
• Interval since radiation completion: [Duration since date, or N/A] (If <12 weeks post-RT, provide explicit justification below.)
• Interval since last systemic therapy: [Duration since date, or N/A]
• Rationale for timing: [Why scan timing is appropriate relative to therapy, inflammatory changes, and pending decisions]
• Upcoming milestone requiring results: [Tumor board date / surgery date / treatment decision deadline]

Exam Specifications

(Include only if requesting non-standard parameters; otherwise omit this section.)

• Coverage extent: [Justification if requesting whole-body beyond skull base to mid-thigh]
• Tracer: [Justification for non-FDG tracer with disease-specific rationale]
• Diagnostic CT: [Medical necessity for contrast-enhanced diagnostic CT if requested]

Supporting Documents

[List of attached documents: clinic note, pathology report, prior imaging reports, tumor marker trend, treatment completion notes as applicable]

Attestation and Contact

I am the treating clinician (or ordering on behalf of the treating oncology team) and attest that PET/CT is medically necessary as described above.

Peer-to-peer contact: [Phone number] | Best callback times: [Availability windows]

Electronic signature: [Clinician name, credentials] | Date: [Date]