Sample Prior Authorization Request Letter
Physician’s name
Physician’s address
Physician NPI
Physician’s fax number
Physicians’ office contact
Patient’s name
Patient’s date of birth
Patient’s health plan name and ID#
Dear Sir or Madam:
This is a request for coverage or prior authorization of a weight loss medication for the above named patient that is indicated for adult patients, who are obese (BMI ≥ 30) or overweight (BMI ≥ 27) WITH a weight-related comorbid condition. This request is for [drug, dosage, amount, and duration]
Primary Diagnosis
E66.01Morbid (severe) obesity due to excess calories
E66.09Other obesity due to excess calories
E66.1Drug-induced obesity
E66.2Morbid (severe) obesity with alveolar hypoventilation including pickwickian syndrome
E66.3 Overweight
E66.8Other obesity
E66.9Obesity, unspecified, NOS
Note: E66.3 needs to be accompanied with a diagnosis for a weight-related comorbid condition (below)
Secondary Diagnoses
Specific BMI (Some health plans may require the inclusion of a more specific BMI designation)
Z68.27 / BMI 27.0 – 27.9 / Z68.36 / BMI 36.0 – 36.9Z68.28 / BMI 28.0 – 28.9 / Z68.37 / BMI 37.0 – 37.9
Z68.29 / BMI 29.0 – 29.9 / Z68.38 / BMI 38.0 – 38.9
Z68.30 / BMI 30.0 – 30.9 / Z68.39 / BMI 39.0 – 39.9
Z68.31 / BMI 31.0 – 31.9 / Z68.41 / BMI 40.0 – 44.9
Z68.32 / BMI 32.0 – 32.9 / Z68.42 / BMI 45.0– 49.9
Z68.33 / BMI 33.0 – 33.9 / Z68.43 / BMI 50 – 59.9
Z68.34 / BMI 34.0 – 34.9 / Z68.44 / BMI 60.0 – 69.9
Z68.35 / BMI 35.0 – 35.9 / Z68.45 / BMI 70 or greater
Note: Z68.27, Z68.28, Z68.29 need to be accompanied with a diagnosis for a weight-related comorbid condition (below)
Weight-Related Comorbid Condition(s) to Support Use of FDA-Approved Medication for Chronic Weight Management(If applicable, please check any that apply)
E11-E11.9Type 2 Diabetes
E78.0 Hypercholesterolemia
E78.1Hyperglyceridemia
G47.33Obstructive sleep apnea
I10Hypertension
E78.5Dyslipidemia/Hyperlipidemia
I25.1-I25.119Cardiovascular disease
M15-M19Osteoarthritis
R73.01Impaired fasting glucose
______Other
Additional Information
(If applicable, please check any that apply)
S/he has tried and failed to maintain weight loss with the following behavior modification(s):
Diet
Exercise
Other: ______
(If applicable, please check any that apply)
This drug is medically necessary because without it this patient is at risk for the following adverse consequences:
Deterioration of the medical condition with risk of hospitalization, permanent disability, or death
Decline in functional ability
Progression of a chronic disease or disability
Surgical intervention
______
(If applicable, please check any that apply)
This request meets the following criteria for medical necessity:
The drug will, or is reasonably expected to, reduce or ameliorate the physical, mental, or developmental effects associated with the illness.
The drug will assist the patient in achieving or maintaining maximum functional capacity in performing daily activities taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age.
(If applicable, please check any that apply)
S/he is unable to take the formulary medication/preferred medication because of:
There are no prescription weight loss medications on the formulary
An adverse reaction
A drug-drug interaction
A contraindication
A failure of a therapeutic trial: [specify which formulary alternatives/preferred medications have been tried and describe results]
______
Please contact my office should you require any additional information.
Sincerely,
Signature