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MODULE 14: DENIALS: ROOT CAUSE ANALYSIS
Section 4: Process Improvement for First-Pass Approvals
Architecting Success: From Reactive Appeals to Proactive Approvals.
SECTION 14.3
Identifying Systemic vs. Case-Specific Issues
The Key to Developing Scalable, High-Impact Solutions.
14.3.1 The “Why”: The Multiplier Effect of Fixing the System
Thus far in your career, your success has been measured one patient at a time. Resolving a complex PA for a single patient is a significant victory. It delivers a tangible, immediate benefit and represents the core of patient advocacy. This is the essential, foundational work of a PA specialist. However, to ascend to the level of a true expert—a leader in the field—you must learn to elevate your perspective from the individual case to the underlying system. This section is dedicated to teaching you that crucial leap: the ability to distinguish between a one-time, isolated error (a case-specific issue) and a recurring, predictable flaw in a process (a systemic issue).
Why is this distinction so critical? Because it determines the scale of your impact. Fixing a case-specific issue helps one patient, one time. It’s a necessary act of repair. But identifying and fixing a systemic issue can prevent dozens, or even hundreds, of future denials. It is not an act of repair; it is an act of re-engineering. It creates a multiplier effect that scales your expertise far beyond the number of hours you have in a day. When you solve a systemic problem, you are creating a permanent improvement in the workflow that benefits every future patient and every staff member who interacts with that process.
This is the transition from being a pharmacist who is good at PAs to being a pharmacist who makes an entire clinic or health system better at PAs. It requires a shift in mindset from a reactive problem-solver to a proactive process improvement analyst. You will learn to use denial data not just to win appeals, but to diagnose the health of a clinical workflow. Is a particular clinic consistently failing to provide necessary chart notes for a specific drug? That’s not ten individual problems; that’s one systemic problem with a single, scalable solution. By learning to see these patterns, you position yourself as a strategic partner to the clinics you support. You move beyond fixing their problems to providing them with the tools and knowledge to prevent those problems from ever occurring. This is the pinnacle of the CPAP role: creating systems that make the right thing to do the easy thing to do, ensuring more first-pass approvals and reducing the need for reactive interventions altogether.
Retail Pharmacist Analogy: The Recurring “Missing SIG” Problem
Imagine it’s a busy Monday. You receive an e-prescription from a local urgent care for amoxicillin suspension for a child. The prescription simply says “Amoxicillin 250mg/5mL,” with no dose, frequency, or duration. This is a case-specific issue. It’s an error, but it’s an isolated one. Your solution is simple and direct: you call the urgent care, get the clarification (“Give 5mL twice daily for 10 days”), document it, and fill the prescription. You have fixed the problem for this one patient.
Now, imagine that over the next two weeks, you receive fifteen more e-prescriptions for pediatric antibiotics from that same urgent care, and every single one is missing the full directions. You now have a systemic issue. The root cause is not a single typo; it’s a flaw in their workflow. Calling the on-duty doctor fifteen separate times is inefficient and treats the symptom, not the disease. Your strategy must evolve.
The systemic solution is to stop fixing the individual prescriptions and start fixing the prescribing process. You don’t just call for a clarification; you call to speak with the clinic manager or lead nurse. Your script changes: “Hi, this is the pharmacist from ABC Pharmacy. I’m calling because we’ve noticed a pattern. It seems like many of your pediatric antibiotic e-prescriptions are transmitting without the directions. I suspect there might be an issue with how the SIG is being entered into your EMR’s free-text field. Could we perhaps look into this? Maybe we can build a dropdown template for the most common antibiotics to prevent this from happening?”
By making that one strategic call, you are no longer just a pharmacist fixing a single error. You are a process improvement consultant. If the clinic implements your suggestion, you will have prevented hundreds of future callbacks, saved hours of work for both your staff and theirs, and ensured that every future pediatric patient gets their medication faster. That is the power of identifying and addressing a systemic issue.
14.3.2 Differentiating the Signal from the Noise: Characteristics of Systemic vs. Case-Specific Denials
The first step in diagnosing a problem is recognizing its symptoms. Systemic and case-specific issues present with different characteristics. Learning to spot these differences is how you begin to see the patterns in denial data.
| Characteristic | Case-Specific Issue (The “One-Off”) | Systemic Issue (The “Pattern”) |
|---|---|---|
| Frequency & Scope |
Isolated Incident: Happens once or very rarely. Affects a single patient or request.
Example: A medical assistant accidentally faxes the PA request for Patient A to the wrong insurance company. This is a simple human error that is unlikely to be immediately repeated. |
Recurring Pattern: The same denial reason appears repeatedly over time. Affects multiple patients, often from the same clinic or for the same drug.
Example: You notice that 5 out of the last 10 requests for a specific infused drug from the oncology clinic have been denied for “missing J-code.” |
| Root Cause |
Unique Circumstance or Simple Error: Often caused by a momentary lapse, a typo, a patient’s unusually complex history, or a one-time misunderstanding.
Example: A denial for “insufficient information” happens because the patient’s specialist appointment, containing the key clinical note, was only yesterday and hasn’t been transcribed into the EHR yet. |
Flawed Process, Knowledge Gap, or Technology Failure: The problem is baked into the standard workflow, a lack of training, or a poorly configured EMR.
Example: The clinic’s standard PA intake form does not have a dedicated field for “prior therapies,” so the staff consistently forgets to include this information, leading to repeated step therapy denials. |
| Required Solution |
Direct Intervention & Correction: A one-time fix for that specific case.
Example: You call the clinic, get the missing lab value for the patient, and submit a corrected request or appeal. The problem is solved for that patient. |
Process Re-design, Education, or Tool Creation: Requires a higher-level solution that changes the workflow for everyone.
Example: You work with the clinic to create a one-page “PA Submission Checklist” for that specific drug, ensuring the staff gathers all required elements upfront for every future patient. |
| Your Diagnostic Clue |
Surprise or Uniqueness: Your reaction is, “That’s odd, I haven’t seen that before.” or “This patient’s situation is really unusual.”
Example: A denial because the patient’s rare genetic marker, required by policy, was documented in an obscure, non-standard lab report that was difficult to find. |
Déjà vu or Predictability: Your reaction is, “Oh, it’s the denial from the GI clinic for Drug X again. I bet I know why.”
Example: You receive a denial for a Crohn’s disease biologic from the GI clinic and correctly predict, before even reading the details, that it was denied for a missing fecal calprotectin level, because that’s the reason for the last five denials. |
14.3.3 The CPAP’s Root Cause Analysis (RCA) Playbook
Once you suspect a systemic issue, you need a structured method to diagnose its origin and develop an effective solution. Root Cause Analysis (RCA) is a formal problem-solving methodology used in high-reliability fields like aviation and healthcare. We will adapt it into a practical playbook for the PA specialist.
A 5-Step Playbook for Systemic Problem Solving
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Step 1: Detect and Quantify the Pattern
You can’t fix what you don’t measure. The first step is to move from a “gut feeling” to hard data. Start a simple denial tracking log (an Excel sheet is perfect for this). Your log should include: Date, Patient, Drug, Payer, Clinic/Provider, Denial Reason (Categorized), and Outcome. When you suspect a pattern, filter your log. For example, “Show me all denials from the Cardiology clinic for Entresto in the last 90 days.” The data will confirm your suspicion. Goal: To be able to state the problem with data: “The Cardiology clinic has an 80% initial denial rate for Entresto, with 90% of those denials due to ‘missing documentation of ACE/ARB failure’.”
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Step 2: Map the Current State Workflow
You must understand the process before you can fix it. Talk to the staff at the clinic (MAs, nurses). Your goal is to create a simple flowchart of how a PA request is currently handled. It might look like this: 1. Provider prescribes Entresto in EHR -> 2. A task fires to the MA’s inbox -> 3. MA opens the PA request in the portal -> 4. MA attaches the last office visit note -> 5. MA submits the request. This visual map often immediately reveals the weak point in the chain.
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Step 3: Perform a “5 Whys” Analysis to Find the Root Cause
This is the core diagnostic technique. Starting with the problem, you ask “Why?” repeatedly until you move past the surface-level symptoms to the foundational cause.
Problem: Entresto requests are being denied for missing ACE/ARB failure documentation.
1. Why? Because the required chart notes showing the ACE/ARB trial were not attached.
2. Why? Because the MAs are only attaching the most recent office visit note.
3. Why? Because their standard workflow for all PAs is to attach only the most recent note, and they don’t know this specific drug has a different requirement.
4. Why? Because there is no specific training or job aid for drug-specific PA requirements.
5. Why? Because the system relies entirely on individual staff memory, which is unreliable for complex, ever-changing payer rules. (This is the root cause).
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Step 4: Develop a Targeted Solution (The “Countermeasure”)
Your solution must directly address the root cause identified in Step 3. Since the root cause is a lack of a reliable system for remembering drug-specific requirements, the solution must be to create one. Brainstorm potential countermeasures:
- Good Solution: An educational in-service to train the MAs on Entresto requirements.
- Better Solution: A durable, laminated “Entresto PA Checklist” taped to the computer monitors in the MA pod.
- Best Solution: Working with the clinic and IT to build the checklist directly into the EHR as a required step or smart-phrase template that fires when Entresto is prescribed.
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Step 5: Implement, Monitor, and Validate
Implement the chosen solution collaboratively with the clinic. Then, continue tracking the data. Set a reminder to check your denial log in 30 and 90 days. Goal: To validate that the solution worked. “After implementing the Entresto checklist on Nov 1st, the initial denial rate for the Cardiology clinic dropped from 80% to 15%.” This closes the loop and demonstrates your value.
14.3.4 Case Study: From Repetitive Appeals to a Systemic Fix
Let’s walk through a complete, real-world scenario to see how a CPAP specialist transitions from case manager to process improvement leader.
The Scenario: The Rheumatology Clinic’s Xeljanz Problem
A CPAP specialist embedded in a health system notes a high volume of time-consuming, peer-to-peer appeals for the drug Xeljanz (tofacitinib) coming from the Rheumatology department for patients with rheumatoid arthritis (RA).
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1
Detection and Quantification
The specialist filters her denial tracking log for “Xeljanz,” “Rheumatology,” and “denial reason” over the past quarter. The data is stark: 25 initial requests, 20 of which were denied (80% denial rate). The denial reason for 18 of the 20 denials (90%) is identical: “Failure to meet medical necessity criteria; no documented trial and failure of a biologic DMARD.” She has quantified the systemic problem.
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2
Workflow Mapping
She meets with the clinic’s lead MA and maps the process. The clinic uses a general “Biologic PA Form” for all of their drugs. The form has a field for “Prior Therapies,” but the MAs typically only list the conventional DMARDs (like methotrexate) because Xeljanz is an oral drug, and they associate “biologics” with injectables. They don’t realize that for payers, Xeljanz (a JAK inhibitor) is positioned *after* a trial of an injectable biologic (like Humira or Enbrel).
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3
The “5 Whys” Analysis
Problem: Xeljanz denied for no trial of a biologic DMARD.
1. Why? Because the prior trial of Humira wasn’t documented on the PA form.
2. Why? Because the MA didn’t think to include it.
3. Why? Because they consider Xeljanz an “oral” drug and the form asks about “biologics,” which they interpret as injectables.
4. Why? Because their internal form and workflow create a false mental categorization that doesn’t match the payer’s clinical policy.
5. Why? Because the clinic’s tools have not been updated to reflect the specific, nuanced place in therapy for JAK inhibitors. (Root Cause)
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4
Developing the Countermeasure
The specialist realizes that retraining alone won’t work because the confusing form will still exist. She proposes a systemic solution: Modifying the “Biologic PA Form.” She works with the clinic manager to add a specific, hard-to-miss section:
“— For JAK Inhibitors (Xeljanz, Rinvoq, Olumiant) ONLY —“
This section includes a mandatory checkbox and field: “[ ] Documented trial of biologic DMARD (e.g., Humira, Enbrel). Please specify drug and failure reason: ______________” -
5
Implementation and Validation (The Result)
The new form is implemented. The CPAP specialist continues to track the data. In the next quarter, the Rheumatology clinic submits 30 requests for Xeljanz. The initial denial rate drops from 80% to 10%. The two denials that occur are for unique, case-specific reasons, not the previous systemic failure. The specialist has saved the clinic, the payer, and her own department countless hours of rework and has significantly accelerated patient access to therapy.
14.3.5 Critical Pitfalls in Systemic Improvement
While the impact of fixing systemic issues is enormous, the process is fraught with interpersonal and logistical challenges. Awareness of these traps is essential for success.
Human Factors: The Hardest Part of Process Improvement
- The Blame Game vs. Process Focus: It is absolutely critical that your analysis focuses on the process, not the people. The goal is not to find out “who is messing up,” but “where is the process letting our staff down?” Trap: Approaching a clinic with an accusatory tone (“Your MAs keep forgetting to…”). This creates defensiveness and shuts down collaboration. Solution: Frame the issue collaboratively and system-focused. “I’ve noticed the payers have a tricky requirement for this drug, and our current workflow doesn’t make it easy to remember. How can we build a better process together?”
- Trying to Boil the Ocean: When you first start looking for systemic issues, you will see them everywhere. The temptation is to try and fix everything at once, overwhelming yourself and the clinics you support. Trap: Creating a massive, 10-point plan to overhaul the entire PA process for a clinic. This is destined for failure. Solution: Use your data to prioritize. Start with the single most frequent and time-consuming denial. Get a small, measurable win. Success breeds trust and makes it easier to tackle the next problem.
- Imposing Solutions vs. Co-designing Them: As the PA expert, you may see the “perfect” solution immediately. However, a solution that is not embraced by the frontline staff who have to use it is a worthless solution. Trap: Designing a beautiful, complex new form or checklist in a vacuum and then “giving” it to the clinic staff. They will likely ignore it and revert to their old habits. Solution: Practice collaborative design. Bring your analysis to the clinic staff and ask them, “Here is the problem. What ideas do you have for a tool that would make this easier for you in your daily workflow?” A simple solution they help create is infinitely more effective than a perfect solution they resent.
SECTION 14.4
Process Improvement for First-Pass Approvals
An exploration of proactive strategies to increase the “clean claim” rate.
14.4.1 The “Why”: Shifting from Defense to Offense
For the entirety of this module, we have focused on the science of reaction. We have learned to dissect denials, diagnose their root causes, and build compelling appeals. This is the defensive side of the game—mastering the art of responding to a payer’s “no.” It is an absolutely essential skill set. However, the ultimate goal of a CPAP is not just to be an expert at winning appeals, but to create a system where fewer appeals are necessary in the first place. This section marks a critical pivot in our strategy and your role: we are moving from defense to offense.
A “first-pass approval” or “clean claim” is a submission that is so complete, so well-documented, and so perfectly aligned with payer policy that it is approved on the very first attempt without clarification or denial. Every first-pass approval represents a massive win for the entire healthcare system. For the patient, it means immediate access to therapy and avoids the anxiety of delays and denials. For the provider’s office, it eliminates the administrative rework, phone calls, and faxes associated with an appeal. For the payer, it reduces the operational cost of having multiple reviewers touch the same case. For you, the specialist, it frees up your valuable time from repetitive, preventable denials, allowing you to focus on the truly complex cases that require your advanced clinical skills.
The “Why” of this section is to instill in you the mindset of an architect. Your job is not just to repair flawed submissions, but to design a better system of submission from the ground up. This involves a proactive, upstream approach. Instead of fixing problems at the end of the line (after the denial), you will learn to embed quality and completeness at the very beginning of the line (before the submission is ever sent). This is the most advanced application of your expertise. It requires you to leverage your deep knowledge of payer policies, not to fight denials, but to pre-emptively build denial-proof submissions. We will explore the practical tools for this architectural work: designing smarter intake forms, creating high-impact educational tools for clinic staff, and developing evidence-based templates that structure the perfect submission every single time. This is how you transition from being a valuable team member to an invaluable strategic asset.
Retail Pharmacist Analogy: Proactive DUR Intervention
In your pharmacy, a significant portion of your time is spent resolving Drug Utilization Review (DUR) rejections. A prescription comes in for a patient on an ACE inhibitor, and the prescriber adds an ARB. The computer flashes a “Therapeutic Duplication” warning. This is a reactive scenario. You must now stop your workflow, investigate the patient’s profile, and call the prescriber to resolve the issue. You are fixing a problem that has already occurred.
Now, consider a proactive approach. You know that a certain new physician in town frequently makes this specific error. Instead of waiting for the next rejection, you take the initiative. You create a one-page “Cardiology Prescribing Pearls” sheet. On it, you include a clear, concise bullet point: “Reminder: Concurrent use of ACE inhibitors and ARBs is not recommended and will result in a pharmacy rejection. Please discontinue one agent before starting the other.” You fax this educational sheet to the new physician’s office.
This single, proactive act is a form of process improvement. You have moved “upstream” to prevent the problem. You are no longer just the pharmacist who calls to fix the duplication; you are the pharmacist who helps the prescriber avoid making the error in the first place. The result is a dramatic decrease in those specific DUR rejections. The workflow becomes smoother, patients get their correct medications faster, and you’ve saved yourself and the doctor’s office future phone calls.
Developing tools for first-pass approvals is the exact same principle applied on a larger scale. Instead of just being an expert at appealing “missing ACE/ARB trial” denials for Entresto, you will create a checklist that ensures the clinic staff documents that trial correctly on the very first submission. You are moving from fixing the claim to perfecting the process, transforming your role from a safety net into a launchpad for success.
14.4.2 Masterclass: The Anatomy of a Perfect, “Denial-Proof” Submission
Before we can build tools to improve the process, we must first define our target. What does a perfect, “first-pass” submission actually look like? It is a package of information so clear, complete, and compelling that it makes an approval the easiest possible decision for the payer’s clinical reviewer. It anticipates their questions and provides the answers upfront.
1. Flawless Administrative Data
The foundation. Any error here invalidates everything else. The submission is checked for 100% accuracy against the patient’s insurance card and provider records.
2. A Coherent Clinical Story
The submission includes a concise Letter of Medical Necessity (LMN) or a clinical summary that tells the patient’s story: diagnosis, symptoms, and the logical reason for the requested therapy.
3. Explicit Policy Alignment
This is the master key. The submission doesn’t just contain data; it explicitly states how that data satisfies the payer’s specific policy criteria (e.g., “Patient meets step-therapy requirements via trial of methotrexate…”).
4. Organized, Relevant Evidence
All necessary supporting documents (lab reports, imaging, specialist notes) are included, clearly labeled, and referenced in the clinical narrative. No more, no less.
The tools we will develop in this section are all designed to consistently produce a submission package that embodies these four core components.
14.4.3 The Proactive Toolkit Part 1: Developing Smarter Intake Forms
The PA process often begins with an internal clinic form—a paper or electronic document used by MAs or nurses to gather the information needed for a submission. A poorly designed form is a primary source of systemic denials. A “smart” intake form, on the other hand, is your first and best tool for ensuring quality at the source.
The Problem with Generic Forms
Most clinics use a single, generic “Prior Authorization Request Form.” It typically includes fields for patient demographics, the drug name, and a space for a diagnosis. The fundamental flaw is that it treats all drugs the same. It fails to prompt the user for the specific, nuanced criteria that payers require for complex, high-cost specialty drugs. This forces the staff to rely on memory—a recipe for failure.
Masterclass Table: Transforming a Generic Form into a Smart Form
Let’s redesign a generic PA form into a “smart” form specifically for a PCSK9 inhibitor (like Repatha or Praluent) for hypercholesterolemia, a class of drugs notorious for its strict PA criteria.
| Generic Form Field | “Smart” Form Field (The Improvement) | Why It Prevents a Denial |
|---|---|---|
| Diagnosis: ___________ |
Specific Diagnosis (Check One):
|
Payers have different criteria for different indications. This forces the user to specify the exact, policy-recognized diagnosis, preventing a denial for “unsupported indication.” |
| Prior Meds: ___________ |
Statin History (Required):
Patient must be on maximally tolerated statin therapy.
|
This directly addresses the most common denial reason: failure to meet step therapy. It makes it impossible for the staff to forget to document the two required prerequisite therapies. |
| Supporting Labs: Attach any |
Qualifying Lipid Panel (Must be within last 90 days):
(Reminder: LDL must be >70 for ASCVD or >100 for HeFH) |
This prevents denials for “insufficient clinical information.” It forces the user to provide the specific lab value the payer needs to see and reminds them of the policy’s required threshold. |
| Notes: ___________ |
Attestation Statement (Provider must sign):
“I attest that the patient has been counseled on and is adherent to a heart-healthy diet and lifestyle.” Provider Signature: ___________________ |
Many payer policies include a “lifestyle modification” requirement. While often a soft requirement, including a formal attestation pre-emptively satisfies this criterion, closing another potential door to denial. |
14.4.4 The Proactive Toolkit Part 2: High-Impact Education Tools
Even with smart forms, knowledge gaps in a busy clinic can persist. Your role as a CPAP extends to being an educator. Developing simple, targeted, and durable educational tools (or “job aids”) is a high-leverage activity that empowers clinic staff to become more autonomous and accurate.
The “PA Playbook” Concept: One Page, All the Rules
The most effective educational tool is not a lengthy training session or a dense email. It’s a one-page “PA Playbook” for a specific, high-problem drug or drug class. This document is designed to be laminated and taped to a wall or monitor. It distills an entire 20-page payer policy into the 5-6 essential things the staff needs to know to get an approval.
PA Playbook: CGRP Inhibitors for Migraine Prevention (e.g., Aimovig, Emgality)
Diagnosis Criteria
- Must be for Migraine Prevention, not acute treatment.
- Patient must have ≥ 4 migraine days per month.
- Must be prescribed by or in consultation with a Neurologist.
Step Therapy Requirements
- Trial & failure/intolerance to TWO of the following classes:
- 1. A Triptan (e.g., Sumatriptan)
- 2. An Antiepileptic (e.g., Topiramate)
- 3. An Antidepressant (e.g., Amitriptyline)
Required Documentation Checklist
- [ ] Chart note confirming diagnosis of migraines.
- [ ] Patient’s migraine diary or note documenting frequency (≥4/month).
- [ ] Note from Neurology consult (if applicable).
- [ ] Chart notes detailing failure/side effects of the two required prior therapies.
Common Denial Trap!
Saying “patient tried Topiramate” is not enough. You must include the dose, duration, and specific reason for failure (e.g., “Topiramate 100mg daily for 90 days, discontinued due to cognitive slowing.”).
14.4.5 The Proactive Toolkit Part 3: Evidence-Based Submission Templates
The final piece of the proactive toolkit is standardizing the clinical narrative itself. A well-structured Letter of Medical Necessity (LMN) that anticipates and directly addresses the payer’s policy criteria can be the deciding factor in a complex case. Creating templates for common scenarios ensures that no critical data point is ever omitted.
These templates are not meant to be rigid, “copy-and-paste” documents. They are structured guides that prompt the user to fill in the patient-specific details in a format that is optimized for clinical review. They transform a blank page into a logical, evidence-based argument.
Template Showcase: LMN for a Non-Formulary Exception
This template is designed for one of the toughest scenarios: requesting a drug that is not on the formulary. It forces the writer to construct a compelling argument based on clinical failure of all covered alternatives.
Letter of Medical Necessity Template: Non-Formulary Exception Request
Date: [Date]
Payer Name: [Payer]
Payer Fax: [Fax Number]
Patient Name: [Patient Name], DOB: [Patient DOB], ID: [Patient ID]
Reference Case #: [PA Case Number, if applicable]
RE: Request for Non-Formulary Exception for [Requested Drug Name]
Dear Clinical Reviewer,
I am writing to request a non-formulary exception for my patient, [Patient Name], for the use of [Requested Drug] for the treatment of [Diagnosis]. This letter outlines the medical necessity of this agent and details the patient’s clinical failure of all available formulary alternatives.
1. Summary of Clinical History:
[Provide a 2-3 sentence summary of the patient’s condition, including duration, severity (e.g., baseline disease activity scores, symptoms), and impact on quality of life.]
2. Failure of Formulary Alternative #1: [Name of Formulary Drug A]
- Treatment Dates: [Start Date] to [End Date]
- Dose(s) Used: [Dose, e.g., 50mg weekly]
- Clinical Outcome: [Be specific. E.g., “After 12 weeks of therapy, patient’s DAS28 score only improved from 5.8 to 5.2, indicating an inadequate response.”]
- Reason for Discontinuation: [Lack of efficacy or specific intolerable side effect.]
3. Failure of Formulary Alternative #2: [Name of Formulary Drug B]
- Treatment Dates: [Start Date] to [End Date]
- Dose(s) Used: [Dose]
- Clinical Outcome: [Be specific.]
- Reason for Discontinuation: [Lack of efficacy or specific intolerable side effect.]
(Add sections as needed for all required formulary alternatives.)
4. Rationale for Requested Agent:
Given the patient’s failure to respond to or tolerate all available formulary agents, [Requested Drug] is now medically necessary. [Provide a 1-2 sentence rationale, e.g., “It offers a different mechanism of action that is likely to be effective in this refractory patient case.”]. We anticipate that treatment with this agent will result in [Desired Clinical Outcome].
Attached, you will find the relevant chart notes documenting the treatment failures outlined above. Thank you for your time and consideration. Please feel free to contact my office if you require any additional information.
Sincerely,
[Provider Name, MD/DO]
[Clinic Name and Contact Information]
