Posting this under the heading it deserves: Prior authorisation: what the criteria usually require — a second dataset Everything below is what sits behind that.
Posting a small dataset on Prior authorisation. It is mine, it is uncontrolled, and the method is stated so it can be discounted appropriately.
What I would like is not agreement but a second dataset collected by someone with no stake in mine. If one exists I would rather read it than argue for this one.
Narrowing the opening post, because the general version has more than one answer.
The most useful reply I ever got about Prior authorisation was a request to state my units. It sounds like pedantry and it has saved me twice.
Tier placement and step therapy: some formularies place a medication on a higher tier or require you to fail cheaper alternatives before approving the one you want. Understanding the requirements before treatment starts matters.
The short version is the first sentence; the rest is why.
Seconded. It reads as careful rather than confident, which is the right register.
Prior authorisation came up in a thread eighteen months ago and was answered well. I cannot find it, which is itself the problem, so here is the reconstruction.
The arithmetic in post #4 is right; the assumption feeding it is the part to check.
Date every account in this subcategory. Payer criteria change frequently and the archive keeps posts permanently.
This is the sort of thing the wiki should carry and currently does not.
Answering the question post #6 raises rather than the one it answers.
A clinician's supporting letter that addresses the criteria explicitly is worth considerably more than one that describes the patient generally.
Reading it back, the second half matters more than the first.
Confirming post #7 from a second method, which matters more than confirming it from a second person.
Prior authorisation looks different depending on whether you are reading the primary literature or the summaries of it, and the difference is not in our favour.
I had written a reply contradicting post #6 and deleted it. Here is what survived.
Small methodological point on Prior authorisation: repeating a measurement is cheap and resolves most of what is being argued about here at no cost to anyone.
Nothing here is legal or medical advice, and appeal processes differ enough by jurisdiction and payer that specifics do not transfer.
I would be glad to be shown a cleaner way of putting this.
Post #9 and I disagree about the size of the effect, not about the direction.
What does not work: describing how the decision made you feel, however justified. The reviewer is checking criteria and the job is to make them checkable.
Taking post #13 at face value and following it one step further.
Prior authorisation criteria are usually published by the payer, and reading them before the appointment changes the outcome more than anything else does.
That is one dataset and I would not build a rule on it.
Everything in post #13 holds. The case it does not cover is the one I have.
The version of Prior authorisation that circulates here is a simplification of a simplification. It is not wrong, but it has lost the conditions under which it holds, and those conditions are where the interesting cases live.
Thank you for the correction. I would rather find out here than later.
I had written a reply contradicting post #17 and deleted it. Here is what survived.
Formulary changes happen on a published schedule, so a denial now may be answering criteria that change shortly.
Confirming post #17 from a second method, which matters more than confirming it from a second person.
Where an exception process exists separately from an appeal, they are different routes with different criteria and using the wrong one loses time.
I would be interested in a counterexample if anyone has one.
The single most useful preparation is obtaining the actual criteria document rather than working from what somebody was told on the phone.
It is worth checking rather than assuming, which costs nothing.
This follows post #22 rather than contradicting it.
Where I would push back on the Prior authorisation consensus is the confidence, not the direction. The direction looks right. The confidence is borrowed.
What does not work: describing how the decision made you feel, however justified. The reviewer is checking criteria and the job is to make them checkable.
Posting it because the silence on this was starting to look like agreement.
Following this. I have the same question and no better information than the first post.
Keep every document with dates in one place. An appeal months later is assembled from whatever you kept.