Prior Authorization Request (Proton Therapy)

Prior Authorization Request – Proton Beam Therapy

Document Header

Patient: [Full name], [DOB], [Insurer member ID]

Request Date: [Date of submission] | Requested Start Date: [Anticipated treatment start]

Urgency: [routine / expedited] (If expedited, include brief clinical rationale.)

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

Treating Facility: [Facility name and full address]

Diagnosis: [Plain-language diagnosis] [ICD-10 code(s)] – [Anatomic site and laterality] (If pathology or staging is pending, use working/presumed language and state what is pending.)

Requested Modality: Proton beam therapy – [IMPT (pencil beam scanning) / passive scatter / TBD]

Payer Reference: [Portal/case number / Prior denial reference / Pending]

Executive Summary

• Confirmed diagnosis and stage/risk group: [Diagnosis] – [TNM and stage group or risk category] (Include staging date and source: clinical, pathologic, or imaging.)
• Treatment intent: [curative / adjuvant / neoadjuvant / salvage / definitive / palliative / re-irradiation]
• Planned targets: [Primary volume(s)] ± [Elective/involved nodal regions] (State laterality and field extent.)
• Requested dose/fractionation: [Total dose in Gy or Gy(RBE)] in [Number of fractions] ([Dose per fraction])
• Patient-specific rationale for PBT: [One-sentence reason tied to OAR proximity, prior RT dose, integral dose reduction, pediatric/AYA status, or other unique factor]
• Comparative planning status: [Completed photon comparison / In progress / Will submit post-simulation by (date)]
• Key OAR considerations: [Critical structures at risk with relevant constraints or tolerance concerns]
• Attachments: [List key attached documents]

[Medical necessity summary statement explaining why photon-based planning cannot meet OAR constraints or would materially increase clinically meaningful toxicity for this patient, and how proton therapy enables adequate target coverage while respecting normal tissue limits]

Diagnosis, Staging, and Clinical Context

[Histology and grade], [Biomarkers/receptors/molecular features relevant to RT planning or risk stratification]. Primary site: [Anatomic site and laterality]. Involved regions: [Regional/nodal involvement and extent]. Staging: [TNM and stage group] (Source: [clinical / pathologic / imaging]; Date: [Date]). Risk stratification: [Risk group with relevant factors such as PSA, Grade Group, T category if applicable]. Patient-specific anatomic/physiologic constraints: [Single kidney, prior transplant, IBD, collagen vascular disease, prior field overlap, or other relevant factors]. Key dates: [Biopsy/pathology date], [Imaging/staging dates]. (If staging or pathology is pending, state explicitly what is pending and expected availability date; avoid definitive language until confirmed.)

Prior and Concurrent Cancer Therapy

(Include this section when prior therapy constrains current planning; otherwise omit entirely.)

• Surgery: [Date], [Procedure], [Margin status], [Reconstruction/implants affecting geometry]
• Systemic therapy: [Regimen], [Dates], [Intent], [Effects relevant to RT tolerance]
• Prior radiation therapy: [Disease/site], [Modality], [Total dose and fractions], [Dates], [Key OAR doses], [Cumulative dose concerns] (If records are being retrieved, note retrieval status and source; do not assert cumulative constraints until verified.)

(If prior RT exists, explicitly frame this request as re-irradiation and document measures to respect cumulative tolerances.)

Alternatives Considered

[Brief rationale for radiation at this time: disease status, intent, and time sensitivity]

• IMRT/VMAT with IGRT: [Patient-specific reason inadequate: specific OAR constraint violation, unacceptable toxicity risk, or inability to achieve adequate target coverage]
• 3D conformal RT: [Reason inadequate for this anatomy/coverage requirement or OAR proximity]
• SBRT/SRS: [Reason infeasible or unsafe: motion, size, location, OAR dose constraints] (Include only if anatomically relevant.)
• Brachytherapy: [Reason not appropriate: anatomical access, prior surgery, dosimetric limitations] (Include only if relevant to disease site.)

(Anchor each alternative's inadequacy to patient-specific anatomy, motion, or quantitative constraints rather than generic statements.)

Requested Proton Therapy Plan

• Targets: [GTV, CTV, PTV definitions]; [Laterality]; [Elective nodal coverage if applicable]
• Prescription: [Total dose in Gy or Gy(RBE)] in [Number] fractions ([Dose per fraction]); [Simultaneous integrated boost: yes / no]
• Technique: [IMPT / passive scatter]; [Number of fields]; [Beam arrangement rationale]
• Motion management: [Free-breathing / DIBH / gating / 4DCT / abdominal compression]; [Immobilization device]
• Image guidance: [Daily volumetric imaging / orthogonal kV / surface guidance]; [Alignment strategy]
• Robustness: [Range/robustness uncertainty parameters incorporated into planning]
• Patient factors: [Positioning tolerance, need for anesthesia, nutrition/support needs, other feasibility considerations]

(If planning is not finalized, use planned/anticipated language and commit to submitting final dosimetric parameters and DVHs after CT simulation.)

Comparative Dosimetry and Clinical Benefit

(Include comparative metrics if planning is complete. Confirm the photon comparator plan was created with clinical intent using best achievable constraints.)

• Target coverage: [CTV/PTV coverage metric] – Proton: [Value], Photon: [Value] – [Clinical interpretation]
• [OAR structure and constraint]: Proton: [Value], Photon: [Value] – [Interpretation: meets constraint / exceeds by X% / meaningful reduction]
• [OAR structure and constraint]: Proton: [Value], Photon: [Value] – [Interpretation]
• [OAR structure and constraint]: Proton: [Value], Photon: [Value] – [Interpretation]
• [OAR structure and constraint]: Proton: [Value], Photon: [Value] – [Interpretation]
• [OAR structure and constraint]: Proton: [Value], Photon: [Value] – [Interpretation]
• Integral dose: Proton: [Value], Photon: [Value] – [Risk reduction interpretation] (Include if tracked.)

[Narrative interpretation: identify specific constraint the photon plan exceeded or unacceptable tradeoff required; describe what proton planning achieves in terms of constraint compliance and/or clinically meaningful dose reduction; explain clinical significance for this patient based on comorbidities, anatomy, or prior therapy; translate dose reductions to expected toxicity reduction and organ function preservation. For pediatric/AYA or genetic predisposition cases, frame integral dose reduction as risk minimization rather than guaranteed outcome.]

(If comparative DVHs are not yet available: do not estimate numeric improvements. Document the anatomic basis for expected benefit and specify the timeline for submission of comparative DVHs and isodose distributions post-simulation.)

Medical Necessity Criteria

• 1. Critical structure proximity / steep dose gradient requirement: [Met / Not Met / Not Applicable] – [Supporting evidence tied to anatomy and constraints]
• 2. Clinically meaningful normal tissue toxicity reduction: [Met / Not Met / Not Applicable] – [OAR constraint compliance or integral dose rationale]
• 3. Re-irradiation / cumulative tolerance concern: [Met / Not Met / Not Applicable] – [Prior RT details and cumulative dose considerations]
• 4. Pediatric/AYA/genetic predisposition: [Met / Not Met / Not Applicable] – [Risk minimization justification]
• 5. Dose escalation beyond standard photon capability: [Met / Not Met / Not Applicable] – [Rationale for why photons cannot safely deliver required dose]
• 6. Patient suitability for reproducible proton delivery: [Met / Not Met / Not Applicable] – [Motion management, body habitus, immobilization tolerance assessment]

Based on the above, proton beam therapy is medically necessary because [brief synthesis linking patient-specific anatomy/constraints, comparative dosimetry findings, and expected clinical benefit].

Patient Counseling and Shared Decision-Making

[Documentation that photon alternatives were discussed with risks and benefits; that proton therapy benefits, risks, and uncertainties were reviewed; and that patient demonstrated understanding and agrees to proceed] (For Medicare prostate cancer cases, this section is required per LCD L35075. Include patient preferences or logistics only if they materially affect feasibility or adherence.)

Requested Services

• Procedure Codes (CPT/HCPCS): [Requested proton delivery and planning/IGRT codes]
• Diagnosis Codes (ICD-10): [Primary and secondary diagnosis codes]
• Fractions: [Number of fractions requested / Range if pending finalization]
• Dates of Service: [Anticipated treatment window]
• Facility Capability: [Equipment statement: pencil beam scanning, image guidance, motion management]

Attachments Index

• 1. Pathology and staging: [Pathology report], [Key imaging reports], [Operative report]
• 2. Treatment planning: [Prescription/treatment plan], [Comparative DVHs], [Isodose distributions]
• 3. Prior therapy records: [Prior RT plan summary and DVHs], [Chemotherapy summaries] (Include if applicable.)
• 4. Multidisciplinary documentation: [Tumor board note], [Relevant specialist consultations]

(Attach only documents that support medical necessity; avoid submitting the entire chart.)

Attestation

Signature: [Physician name], [Credentials], [NPI] – [Date/time]

Contact for Peer-to-Peer: [Direct phone line], [Best times for availability]

Statement: "All statements above are supported by the attached medical record and planning documentation."