Prior Authorization Letter Skill

A prior-auth or medical-necessity letter succeeds when it connects this patient's clinical facts to the insurer's coverage criteria — clearly, with evidence, and with the exact request spelled out. This skill structures that argument so the reviewer can approve it quickly, and so an appeal addresses the stated denial reason head-on.

Clinical-safety note: this is a documentation aid, not medical advice. The clinical justification must reflect the treating clinician's judgement and the patient's actual record; the clinician must review, verify, and sign before submission. Do not invent diagnoses, codes, history, or evidence.

Working from a brief

Given the treatment and a diagnosis, produce the full letter anyway — structure the argument and insert the standard elements, marking patient-specific facts (codes, dates, prior treatments) to be confirmed rather than inventing them. For an appeal, infer and directly rebut the likely denial reason if it's stated. Never fabricate clinical history or citations.

Required Inputs

Ask for these only if they aren't already provided (else mark to confirm):

• Patient & policy — patient identifiers and insurance/policy details (as provided).
• The request — the specific medication/procedure/service, with codes (CPT/HCPCS/ICD-10) if available.
• Clinical justification — diagnosis, severity, relevant history, and why this treatment is medically necessary.
• Prior treatments — what's been tried and failed/contraindicated (step-therapy history).
• If an appeal — the denial reason given by the insurer.

Output Format

Letter of Medical Necessity / Prior Authorization

• Header — date, insurer/UM department, patient name, policy/member ID, and the requesting clinician.
• Re: the specific request and relevant codes (diagnosis + procedure/drug).
• 1. Request — one sentence stating exactly what authorization is sought.
• 2. Patient clinical picture — diagnosis, severity, functional impact, and pertinent history (verified facts only).