Prior Authorization Request (Wake-Promoting Medication)

Date of request: [Date]
Urgency: [routine / expedited] (If expedited, include reason: [imminent safety risk / work restriction / other] with brief justification.)
Patient name: [Full name]   DOB: [MM/DD/YYYY]   Member ID: [ID]   Phone: [Patient phone]
Ordering clinician: [Name, credentials]   NPI: [NPI]   Tax ID: [Tax ID]
Clinic address: [Street, City, State ZIP]   Phone: [Clinic phone]   Fax: [Clinic fax]
Payer/PBM: [Plan name]   BIN/PCN/Group: [If known]   PA reference #: [If available]
Medication requested and indication: [Medication name] for [EDS due to narcolepsy / idiopathic hypersomnia / residual sleepiness in treated OSA]

Medical Necessity Snapshot

[4–8 sentence executive summary] (Identify diagnosis and duration; report validated sleepiness score with date; quantify functional and safety risk; cite the single most persuasive objective finding with dates and key values such as mean sleep latency, SOREMP count, or PAP adherence with residual AHI; summarize prior therapies and outcomes; conclude with requested medication, dose, and why medically necessary now. If objective data are limited or pending, state this and direct reviewer to relevant section.)

Medication Requested

• Medication: [Generic (Brand)], [formulation], [strength]
• Dose and schedule: [Dose] [frequency] (Include titration plan if drug requires staged dosing or payer limits early quantity.)
• Quantity per fill / Days' supply / Refills: [Quantity] / [Days] / [Refills] (If quantity payer-dependent: "Standard dispensing requested; final quantity per plan limit.")
• Start date and anticipated duration: [Start date]; [Duration or ongoing]
• Diagnosis/Indication with ICD-10: [Diagnosis] ([ICD-10 code])
• Regulatory status: [FDA-labeled / off-label] (If off-label, note clinical rationale is detailed in Plan section.)

Diagnosis and Diagnostic Basis

(Include only the applicable diagnostic module(s). Use dates and key values. Do not state criteria are met without supporting data.)

Narcolepsy (Type [1 / 2])

• Clinical syndrome: [EDS duration, stating if ≥3 months]; [sleep attacks]; [refreshing naps]; [nocturnal sleep quality]; [REM intrusion symptoms if present: sleep paralysis, hypnagogic/hypnopompic hallucinations]
• Cataplexy: [Triggers, frequency, injury risk] (Omit if not present.)
• Objective testing: [Overnight PSG date/location with adequacy confirmation]; [MSLT date, mean sleep latency, SOREMP count]; [CSF orexin/hypocretin if tested with date and value]
• Testing conditions: [Adequate prior sleep confirmed / medication washout / deviations and rationale]
• Exclusions considered: [Insufficient sleep and circadian misalignment addressed]; [medication/substance contributors assessed]; [medical/psychiatric conditions considered]

Idiopathic Hypersomnia

• Clinical syndrome: [EDS duration, stating if ≥3 months]; [non-restorative long naps]; [sleep drunkenness]; [prolonged sleep time if present]; [functional impairment]
• Objective characterization: [MSLT mean sleep latency and SOREMP count with date]; [total sleep time documentation if long-sleep phenotype via 24-hour PSG or ≥7-day actigraphy/sleep log with dates and average]
• Rule-outs: [Insufficient sleep syndrome assessment method]; [circadian rhythm disorder assessed]; [other sleep disorders treated/excluded]; [medication/substance effects assessed] (State what is pending or why not obtained if applicable.)

Residual Sleepiness in Treated OSA

• Baseline OSA diagnosis: [Diagnostic study date and type]; [baseline AHI/RDI]; [oxygen nadir]; [baseline symptoms]
• Current OSA therapy and adequacy: [Therapy type]; [treatment duration and stability]; [objective adherence summary with date range]; [residual AHI]; [leak and pressure settings if relevant]
• Residual EDS characterization: [Persistent sleepiness quantified with scale and date]; [sufficient sleep opportunity confirmed]; [evaluation for other causes: insufficient sleep, circadian disorder, depression, sedating medications, other sleep disorders]
• Adjunctive therapy statement: Wake-promoting medication is adjunctive; primary OSA therapy continues.

Objective Sleep Testing and Supporting Data

(Include subsections that apply. Use dates and data ranges. Use table format when multiple studies exist.)

PSG Summary

Date	Type	AHI/RDI	O2 nadir	Sleep efficiency	Notes
[MM/DD/YYYY]	[Diagnostic / titration / split-night]	[Value]	[%]	[%]	[Key findings, whether preceded MSLT]

(Remove table if single study; use narrative format instead.)

MSLT Summary

• Date: [Date]   PSG night before: [yes / no]   Mean sleep latency: [minutes]   SOREMPs: [count]   Deviations: [none / describe]

MWT Summary

• Date: [Date]   Protocol: [40-min / 20-min]   Mean sleep latency: [minutes]   Indication: [safety-sensitive occupation / driving risk / return-to-duty]

(Include only when safety or fitness-for-duty documentation is required.)

Actigraphy and Sleep Diary

• Monitoring dates: [Date range]   Average TST: [hours]   Schedule regularity: [description]

PAP Device Download

• Date range: [Dates]   Nights used: [%]   ≥4h nights: [%]   Avg hours/night: [hours]   Residual AHI: [value]   Leak: [value]   Pressure: [settings]

(If objective download unavailable, state adherence is patient-reported and document plan to obtain download.)

Symptom Quantification

• Scale: [Epworth Sleepiness Scale / other]   Score: [value]   Date: [date]   Trend: [prior scores if relevant]

Functional Impact of Excessive Daytime Sleepiness

• Driving risk: [Unintentional dozing, near-miss collisions, accidents, employer restrictions, counseling provided]
• Work/school impairment: [Absenteeism, reduced productivity, disciplinary actions, academic decline]
• ADLs and caregiving: [Childcare safety, cooking hazards, falls]
• Cognitive/psychiatric impact: [Concentration, mood, social functioning]
• Sleep attacks in unsafe contexts: [Contexts and frequency]

(At minimum, document whether driving or occupational safety risk exists. Include brief patient quotes only if they clarify severity.)

Therapy History and Response

Non-Pharmacologic Measures

[Sleep schedule optimization, sleep hygiene counseling, strategic naps] (For OSA: [mask fitting, humidification, pressure adjustments, weight management])

Pharmacologic History

Medication	Dose	Duration	Response	Adverse Effects	Disposition
[Name]	[Dose]	[Dates or duration]	[Response, quantify when possible]	[Adverse effects]	[Stopped / continue / contraindicated]

(Document adequate dose and duration, adherence, and reason stopped. If payer-expected step therapy was not tried, document contraindication or clinical inappropriateness.)

Concurrent Sedating Medications

[Agent and dose]: [Mitigation steps—timing adjustments, deprescribing attempts, alternatives considered]

Assessment

• [Primary sleep disorder diagnosis and severity]
• [Excessive daytime sleepiness with quantified impairment and safety risk]
• [Comorbidities relevant to medication safety: hypertension, arrhythmia risk, psychiatric history, renal/hepatic impairment, pregnancy considerations, substance use history]

(Tie each item explicitly to medical necessity for the requested agent.)

Plan and Medical Necessity Rationale

[Statement that medication is for EDS due to documented diagnosis] (Explain why needed now: persistent symptoms plus safety/functional impairment. Explain why alternatives are insufficient: prior ineffectiveness, intolerance, contraindications. For OSA, state medication is adjunctive while primary OSA therapy continues.)

• Expected outcomes: [Improved daytime wakefulness, reduced unintentional sleep episodes, improved work/school safety, reduced driving risk]
• Monitoring plan: [Follow-up interval]; [BP/HR monitoring if relevant]; [psychiatric symptom monitoring if relevant]; [reassessment measures]; [ongoing PAP adherence checks for OSA]
• Standards alignment: [Statement aligning with sleep medicine treatment standards] (Include if needed for appeal.)

Attestations

• Comprehensive evaluation confirms diagnostic criteria for [documented condition].
• For OSA: Underlying obstruction is treated; PAP therapy continues; wake-promoting medication is adjunctive.
• Patient counseled regarding drowsy driving risk and avoidance of hazardous activities while sleepy.
• PDMP reviewed. (Include if applicable for controlled substances.)

Attachments

• [PSG/MSLT/MWT report(s) with dates]
• [PAP adherence report with date range]
• [Actigraphy/sleep log summary]
• [Prior medication trial documentation]
• [Clinic visit notes documenting symptoms and impairment]
• [Pertinent labs supporting rule-outs]

(If documents not attached, state where/when obtained, which elements missing, records request date, and whether repeat study planned.)

Clinician Signature

Clinician name/credentials: [Name, credentials]
NPI: [NPI]
Signature and date: [Signature / date]
Contact for peer-to-peer: [Direct phone and availability]

(This is a prior authorization narrative for rapid payer review. Use only diagnostic modules that apply. Populate medication trial table only with medications actually tried. If information is unavailable, state what is missing and pending records requests rather than leaving blanks. Omit sections that do not apply to the patient's condition.)