Prior Authorization Request (Surgery/Procedure)

Prior Authorization Request — Surgery/Procedure

Patient Name: [Patient name]

Date of Birth: [DOB]

Member ID: [Member ID]

Group ID: [Group ID] (Include if available)

Payer/Plan: [Payer/Plan name]

Requesting Clinician: [Clinician name, credentials, NPI, phone, fax]

Servicing Facility: [Facility name, address], [ASC / HOPD / inpatient]

Request Type: [initial / resubmission / appeal]; [standard / expedited]

Requested Date of Service: [Requested date of service]

Request Summary

[2–5 sentence executive summary stating diagnosis and key severity features, failed or not tolerated conservative management with durations, objective evidence supporting diagnosis, and the exact procedure requested with intended clinical benefit] (Use short sentences. Quantify severity and duration. Include only information that supports the request.)

• Requested Procedure(s): [Procedure name(s)], [CPT/HCPCS code(s) if known], [laterality/level/site], [outpatient / inpatient]
• Primary Diagnosis: [ICD-10-CM code] — [Plain-language diagnosis]
• Supporting Diagnoses: [Additional ICD-10-CM codes] (Omit if none)
• Medical Necessity Pillars:
  • [Symptom duration and severity]
  • [Failed/intolerant conservative care]
  • [Objective findings correlating with symptoms]
  • [Functional limitation or safety risk]
  • [Progression or red flags] (Include if applicable)

Clinical Indication and Severity

[Focused narrative of clinical problem including onset, duration, course, and symptom pattern/frequency] (Keep concise; omit unrelated problems unless they affect surgical risk or site-of-service.)

Severity: [Pain score and/or quantified symptom severity]; [constant / intermittent] with [frequency details]

Functional Impact: [Walking tolerance, sitting/standing tolerance, sleep disruption, ADL limitations, work restrictions, assistive device use] (Quantify distances, durations, and task limits when available.)

Red Flags/Neurologic Compromise: [Objective neurologic deficits, red flags, or progression] (Include only if present; otherwise omit this line.)

Conservative Management and Prior Treatment

(Present all relevant modalities with precise durations and outcomes. If conservative care was not performed, include a single row stating the explicit rationale. Label patient-reported information as such.)

Treatment Modality	Dates/Duration	Frequency/Intensity	Outcome	Reason Stopped
[Physical therapy]	[Start–end dates or total weeks]	[Number of visits, HEP compliance]	[Improved / Worsened / No change]; [quantified change if known]	[Completed / Plateau / Intolerant / Contraindicated]
[Medications: specific agents]	[Duration]	[Doses/frequency]	[Response]; [adverse effects if any]	[Completed / Intolerant / Ineffective / Contraindicated]
[Injections/procedures: type]	[Date(s)]	[Number of sessions, laterality/level]	[Percent relief and duration of relief]	[Completed / Limited benefit / Temporary relief]
[Bracing/DME/activity modification]	[Duration]	[Use pattern]	[Outcome]	[Discontinued / Ongoing]

Objective Findings

(Include only clinician-observed findings relevant to the requested procedure. Ensure laterality/level matches the request.)

Physical Examination:

• [Neurologic deficits with grades: strength, reflexes, sensation]
• [Provocative/special tests and results]
• [Range of motion, instability, tenderness, deformity]
• [Gait/functional observations]
• [Significant negatives supporting differential] (Include if pertinent)

Imaging:

• [Modality] — [Region] — [Date]: [Key findings relevant to indication]. [Correlation statement linking imaging to clinical presentation]. (Full report attached.)

Additional Diagnostics: (Include only if relevant to coverage criteria)

• [EMG/NCS results, pertinent labs, or other tests]

Diagnosis and Medical Necessity Rationale

• Primary Diagnosis: [ICD-10-CM code] — [Plain-language diagnosis]
• Supporting Diagnoses: [ICD-10-CM codes] (Include only if they directly support the request)

[Concise reasoning linking symptoms and functional impairment to objective exam/imaging findings] (Use language such as "consistent with" or "correlates with." Avoid over-claiming causality.)

Why procedure is indicated now: [Failure/intolerance of conservative measures with durations, severity/progression criteria met, or revision/escalation need] (Quantify lack of improvement; reference guideline or coverage criteria if applicable.)

Alternatives considered: [Briefly list alternatives and reasons not appropriate: prior failure, contraindication, not expected to address pathology]

Coverage policy alignment: [Payer policy or Medicare LCD/NCD reference and how documentation meets criteria] (Include if known; otherwise omit.)

Planned Procedure Details

• Procedure: [Procedure name] — [CPT/HCPCS code if known]
• Anatomic specificity: [Laterality / level / joint compartment / number of lesions]
• Approach/technique: [Open / arthroscopic / endoscopic / percutaneous] (Include only if relevant to coverage)
• Implants/devices/grafts/biologics: [List with model/system if authorization-relevant] (Omit if none)
• Setting and anesthesia: [ASC / HOPD / inpatient]; [local / regional / general / MAC]
• Expected length of stay: [Ambulatory / Observation hours / Inpatient days] (Include if inpatient or observation requested)
• Staged procedures: [Indicate if part of staged plan and anticipated subsequent stages] (Omit if not applicable)

Perioperative Considerations

(Include only if comorbidities affect medical necessity, site-of-service, or timing. Omit entire section if no relevant perioperative factors.)

• [OSA/airway considerations requiring monitored setting]
• [Anticoagulation management plan]
• [Cardiopulmonary risk factors]
• [Diabetes/wound risk optimization]
• [Other relevant comorbidities affecting site-of-service or timing]

Post-Procedure Plan

• Expected outcomes: [Functional goals: improved ambulation, decreased symptoms, return-to-work targets, ADL goals] (Frame as expectations, not guarantees.)
• Rehabilitation: [PT/OT start timeframe and anticipated duration]
• DME needs: [Bracing/walker/other] (Omit if none)
• Follow-up: [Post-op visit schedule]

Attachments Index

(List all supporting documents. If a document is not available, note reason and substitute evidence if provided.)

• Clinic notes ([date range]): [Attached / Not available — reason]
• PT evaluation and progress notes: [Attached / Not available — reason]
• Imaging reports with dates: [Attached / Not available — reason]
• Injection/procedure reports: [Attached / Not available — reason] (If applicable)
• Prior operative reports: [Attached / Not available — reason] (If revision)
• Specialist consult notes: [Attached / Not available — reason] (If applicable)
• PROMs or objective outcome measures: [Attached / Not available — reason] (If used)

Attestation

I attest that this prior authorization request reflects my clinical assessment and is supported by the patient's medical record. All information is accurate to the best of my knowledge.

Treating Clinician Signature: [Electronic signature] — [Name, credentials, NPI]

Date: [Date of attestation]

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

(Do not backdate. Use an addendum for corrections or late documentation.)