Six years of fighting this. The single biggest factor is not the medical evidence, it is whether the request answers the specific criterion the reviewer has in front of them.
Every prior auth is scored against a checklist. The reviewer is not reading your file for a story, they are matching phrases. So: get the payer’s own criteria document, find the exact bullet points, and have the prescriber’s letter quote them back almost verbatim with the evidence for each.
What that looks like in practice:
- “Criterion 3a requires failure of at least two agents from the following list. The patient has failed A (six weeks, discontinued for side effects) and B (twelve weeks, inadequate response).”
- Not: “I have tried several medications without success.”
Also: appeal is a different process with a different reviewer and a much higher success rate than the initial request. People give up at the first denial and the first denial is the routine one.
This should be required reading. Half the denials I hear about are paperwork artefacts, not clinical decisions.
How do you get the criteria document? Mine was not on the website.
Ask the prescriber’s office, they often have it. Otherwise request it — some states require the payer to provide the criteria on request, and the request itself is sometimes enough.
Six years of this and I never once got the criteria up front. This is a much better method than mine, which was shouting.
And keep the denial letter. It has to cite a reason, and the reason tells you which criterion you failed. The reason is the instruction manual.