Prior Authorization Request (Transplant Surgery)

Prior Authorization Request – Transplant Surgery (Medical Necessity Summary)

Document Header and Routing

• Date Prepared: [Date]
• Requesting Provider: [Provider name], [Credentials], [Specialty role], NPI: [NPI]
• Transplant Program: [Facility name], [Address], Phone: [Phone], Fax: [Fax], Tax ID: [Tax ID]
• Utilization Management Contact: [Name], [Role], Phone: [Phone], Fax: [Fax], Email: [Email], Peer-to-peer availability: [Days/times and time zone]
• Payer Information: [Payer name], [Plan type], [Portal/fax destination], Payer reference #: [Reference number if known], Case manager: [Name and contact if known]

Patient and Coverage Identification

• Patient: [Name], DOB: [DOB], MRN: [MRN]
• Coverage: Member ID: [ID], Group #: [Group number], Coverage type: [Primary / Secondary]
• Authorization Class: [Standard / Expedited] (If expedited, include clinical rationale in Urgency section)

Request Snapshot

• Request Type: [Transplant evaluation / Listing authorization / Transplant admission-procedure / Living donor evaluation / Living donor surgery-admission / Post-transplant therapy / Multi-organ transplant]
• Requested Services:
  • Service Line 1 (Repeat for each service line)
    • Procedure and organ: [Procedure name], [Organ]
    • Approach: [Deceased donor / Living donor], [Single organ / Multi-organ], [Open / Minimally invasive]
    • CPT/HCPCS: [Code(s) / Pending] (Do not infer codes; if pending, note expected submission timeframe)
    • ICD-10 diagnosis codes: [Primary diagnosis code], [Key comorbidity codes]
    • Place of service: [Inpatient hospital / Outpatient / ASC / Other]
    • Facility: [Facility name]
    • Requested start/admission date: [Date or date range]
    • Anticipated duration/LOS: [Duration or LOS range]
• Urgency: [Routine / Expedited] — [Brief rationale for urgency classification]
• Decision Needed: [One-sentence authorization request statement]

Executive Clinical Summary

[6–12 sentence narrative summarizing: patient diagnosis and organ failure status, what is being requested, why it is medically necessary now, severity markers with dates, alternatives tried or unsuitable, expected benefit, and immediate clinical plan] (Use plain language with minimal abbreviations; include key numeric severity markers inline)

Clinical Indication and Urgency

• Primary Indication: [Organ system], [Diagnosis with etiology and stage], Onset: [Date or approximate date], Objective criteria for end-stage status: [Criteria with dates]
• Complications Driving Urgency: [Recent admissions with dates and reasons], [ICU stays], [Life-support requirements], [Refractory complications], [Functional status impact] (Include dates for all objective events)
• Organ-Specific Urgency Metrics: (Include applicable organ type)
  • Liver: MELD/PELD: [Score] (Lab date: [Date]); Exception status: [Yes / No], [Details if yes]; Score trend: [Trend over 30–90 days]
  • Heart: Medical urgency status: [Status 1–6] (Date assigned: [Date]); Current advanced therapies: [IABP / Impella / ECMO / Durable VAD / Inotropes] (Start dates: [Dates])
  • Lung: Composite Allocation Score (CAS): [Score] (Date: [Date]); Key components: [Oxygen requirements, FEV1, 6MWD, etc. with dates]
  • Kidney: Dialysis start date: [Date]; Access issues: [Details if applicable]; Sensitization (PRA/CPRA): [Percentage] (Date: [Date]); Wait time credit start: [Date]
  • Multi-Organ: Organs requested: [List]; Rationale for multi-organ necessity: [Criteria with dates]
• Clinical Trajectory (30–90 days): [Trend in severity scores], [Admissions with dates], [Organ failure markers with dates], [Recent changes prompting this request]

Prior Treatments and Alternatives

• Treatments Attempted:
  • [Medication class / Device / Therapy], Dates: [Start–Stop or ongoing], Outcome: [Response / Failure / Intolerance / Contraindicated]
  • [Bridge therapy if applicable], Dates: [Dates], Outcome: [Brief outcome]
• Why Alternatives Are Insufficient: [Explanation of why each alternative is contraindicated, failed, not durable, or not expected to alter mortality/trajectory; if bridge therapies in place, explain why bridge-only]

Transplant Evaluation Summary

(Include for evaluation completion, listing, or surgical authorization requests; omit if not applicable)

• Medical Evaluation: [Key comorbidities assessed], [Organ-specific clearance statuses]. Conclusion: [Medically suitable / Requires optimization / Not yet cleared]
• Surgical Evaluation: [Technical considerations, anatomic issues, prior surgeries, vascular access]. Conclusion: [Operative candidacy statement]
• Infectious Disease: [Screening status], [Chronic infection management if applicable], [Vaccination status]. Conclusion: [Cleared / Cleared with plan / Pending]
• Malignancy Screening: [Studies completed], [Findings]. Conclusion: [No active malignancy / Surveillance plan]
• Immunologic: Blood type: [ABO/Rh] (Date: [Date]); HLA/PRA/DSA: [Values with dates]; Crossmatch plan: [Plan if living donor]. Conclusion: [Immunologic risk assessment]
• Psychosocial: [Support system], [Adherence assessment], [Substance use assessment status], [Mental health stability]. Conclusion: [Meets program criteria / Needs additional support / Pending] (Include only candidacy-relevant content)
• Nutrition/Functional Status: BMI: [Value] (Date: [Date]); Frailty assessment: [Score if used] (Date: [Date]); Optimization plan: [Plan if needed]. Conclusion: [Nutritional/functional readiness]

Procedure and Admission Plan

(Include for transplant admission/surgery or donor surgery requests; omit if not applicable)

• Planned Procedure: [Organ(s)], [Deceased donor / Living donor], [Single / Multi-organ], [Approach]. Anticipated timing: [Date/window or pending offer]
• Admission Plan: Expected level of care: [ICU / Stepdown / Floor]; Anticipated LOS: [Range]
• Key Risks and Mitigation: [Major perioperative considerations and mitigation strategies]
• Facility Confirmation: Transplant program: [Name]; Surgeon of record: [Name, credentials]; Approved transplant center: [Yes / Certification ID if required]

Living Donor Module

(Include only for donor evaluation or donor surgery requests; for recipient requests, state: "Living donor evaluated and cleared per program protocol" without donor PHI unless payer requires)

• Donor Identification: [Name], DOB: [DOB], MRN: [MRN], Coverage: [Identifiers] (Include only in separate donor authorization)
• Consent and Advocacy: [Statement confirming donor informed consent and independent donor advocacy in place]
• Donor Evaluation Status: [Medical evaluation findings and suitability], [Psychosocial evaluation status], Compatibility: [ABO], Crossmatch: [Result / Planned date]. Conclusion: [Suitable donor / Pending items]
• Donor Procedure Plan: [Procedure type], Admission: [Inpatient / Outpatient], Expected LOS: [Range], Follow-up: [Plan]

Post-Transplant Therapy Module

(Include for post-transplant therapy authorization requests; omit if not applicable)

• Transplant Context: Transplant date: [Date], Organ: [Organ], Baseline graft function: [Summary]
• Current Problem: [Rejection type / Infection / Complication] prompting this request
• Evidence: Biopsy: [Result] (Date: [Date]); Labs: [Trends with dates]; Imaging: [Key findings with dates]; Clinical presentation: [Summary]
• Therapy Requested: [Drug / Infusion / Procedure], Dose schedule: [Dose and frequency], Site of care: [Outpatient infusion / Inpatient / Home], Duration: [Planned duration], Monitoring: [Labs and visits]
• Why Alternatives Are Insufficient: [Prior therapy failure or intolerance], [Contraindications], [Risk of graft loss or hospitalization without requested therapy]
• Expected Outcome: [Anticipated improvement with therapy]

Medical Necessity Statement

[3–5 sentence synthesis linking current severity with objective markers and dates, prognosis without requested service, expected outcome change with service, and risk of delay] (Use outcome-linked phrasing: mortality risk, graft loss risk, ICU escalation risk, readmission prevention)

Attachments and Evidence Index

(Mark each as: Attached / Available upon request / Pending with expected date)

• Recent clinic/consult note | [Date] | [Status]
• Transplant committee letter/decision | [Date] | [Status]
• Key labs trend report | [Date range] | [Status]
• Imaging summaries (CT/MRI/echo/cath) | [Dates] | [Status]
• Pathology/biopsy reports | [Dates] | [Status]
• Psychosocial clearance | [Date] | [Status]
• Donor evaluation clearance | [Date] | [Status] (If donor request)
• Recent discharge summaries | [Dates] | [Status]
• Allocation score/status documentation | [Date] | [Status]
• Other supporting records | [Date] | [Status]

Attestation and Signature

Attestation: I attest that the information provided is accurate to the best of my knowledge, reflects the patient's current clinical status, and that additional records can be provided within [timeframe] upon request.

• Clinician Signature: [Name], [Credentials], [Role], NPI: [NPI]
• Date/Time: [Date and time]
• Peer-to-Peer Contact: [Direct phone], Availability: [Days/times and time zone]