[Date]
Pharmacy Appeals
[Health plan or pharmacy benefit manager]
[Appeals address or fax]
Re: Expedited appeal of prior-authorization denial for [Medication, dose, and formulation] for [Patient name], DOB [Date of birth], Member ID [Member ID], Reference [Denial or case reference number]
To the appeals reviewer:
I am the treating child and adolescent psychiatrist for [Patient name], a 9-year-old whom I have evaluated and treated. I am writing to appeal the plan's determination dated [Date of denial] denying coverage of [Medication, dose, and formulation], and to request that the plan authorize it as prescribed.
I am requesting that this appeal be handled on an expedited basis. Interruption or delay of this medication would seriously jeopardize the patient's health and could precipitate the hospitalization or injury that the treatment is preventing. A physician's attestation that an appeal is urgent should be honored as such.
Clinical summary
[Patient name] carries a diagnosis of autism spectrum disorder with severe irritability and aggression. At present the patient has been physically aggressive to a degree that has injured others or created a credible threat of injury, engages in self-injurious behavior, and cannot be maintained safely at home by the family without effective treatment. [Add one to three sentences of specific clinical detail with dates, and any rating-scale scores you use.]
Treatment history
The patient has had two prior medication trials for this condition. These ended in an inadequate response at an adequate dose and duration and discontinuation for adverse effects. [List each agent with dates, maximum dose, duration, and outcome.] Psychosocial treatment has been in place throughout and continues alongside medication. [Name the therapy and its duration.]
Why [Medication, dose, and formulation] is medically necessary
[Medication, dose, and formulation] is a second-generation antipsychotic. Its use in this patient is consistent with the practice parameter of the American Academy of Child and Adolescent Psychiatry, which supports antipsychotic treatment in children and adolescents for severe, impairing target symptoms when psychosocial interventions and, where appropriate, other medication classes have not been sufficient, and when the treatment is paired with the recommended monitoring. Several second-generation antipsychotics carry FDA-approved pediatric indications; where the requested use falls outside the label for this patient's age or diagnosis, it is supported by the evidence cited below and by the standard of care in child and adolescent psychiatry. [If the use is on-label, cite the indication and approved age range from the prescribing information. If off-label, cite one or two sources.]
The patient's age is not a contraindication. The plan's age limit is a utilization edit, not a clinical finding, and a child whose target symptoms meet the threshold above needs the same treatment at nine that a plan would authorize at thirteen.
The denial rests on the patient's age. An age edit is a utilization management rule, and the plan is obliged to make an individualized determination of medical necessity when the edit is appealed. The clinical facts above, not the patient's birth date, decide whether this treatment is necessary.
Monitoring plan
Treatment is being delivered with baseline weight, body mass index, blood pressure, fasting glucose or hemoglobin A1c, and lipids, repeat metabolic monitoring at the intervals recommended in the practice parameter, a structured assessment for abnormal involuntary movements at baseline and on schedule, and tracking of height, weight, and growth velocity. The monitoring plan follows the relevant practice parameter, and results are documented in the record. [Add dates of baseline measures if already obtained.]
Applicable requirements
Because this patient is under twenty-one and enrolled in Medicaid, the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit applies: the state must cover any Medicaid-coverable service, including a covered outpatient drug, that is necessary to correct or ameliorate the patient's condition, and may not deny it on the basis of a limitation written for adults.
Federal Medicaid law also sets the terms of prior authorization for covered outpatient drugs: the program must respond to a prior-authorization request within twenty-four hours and must provide for a seventy-two-hour emergency supply while the decision is pending. Those requirements apply to managed care plans as well as to fee-for-service. The enrollee's appeal rights under the managed care appeal regulations, including the right to a state fair hearing after exhausting the plan's internal appeal, are reserved.
Request
- Reverse the determination and authorize [Medication, dose, and formulation] as prescribed, for [authorization period requested].
- Provide a seventy-two-hour emergency supply while this appeal is pending, as federal Medicaid law requires.
- Before any decision to uphold the denial, schedule a peer-to-peer review with me and ensure the reviewing physician is a board-certified child and adolescent psychiatrist. I can be reached at the number below.
- Provide the specific clinical criteria or formulary policy applied, the reviewer's written rationale, and the reviewer's name, license, and specialty.
- Issue a decision within twenty-four hours of receipt of this appeal.
- Include this letter and its attachments in the complete claim file for any subsequent internal or external review.
I am available to discuss this patient at any time. An interruption in a working medication regimen for a child carries real risk, and I ask that the plan act accordingly.
Sincerely,
[Your name]
[Credentials and board certification]
[Practice or hospital]
[Direct phone and fax]
NPI [NPI]
Enclosures: [Medication history with dates and doses, recent progress notes, rating scales, monitoring results, and any prescribing information or guideline pages cited.]