Download Sample Letter for Prior Authorization Request for BELVIQ ® or

We cannot guarantee payment of any claim. Coding, coverage, and reimbursement may vary significantly by
payer plan, patient, and setting of care. Actual coverage and reimbursement decisions are made by individual
payers following the receipt of claims. For additional information, providers should consult with the patient’s
payer for all relevant coding, reimbursement, and coverage requirements. It is the sole responsibility of the
provider to select the proper code and ensure the accuracy of all claims used in seeking reimbursement. All
services must be medically appropriate and properly supported in the patient medical record.
If you choose to use this sample letter, please remove or replace all red text, including this box, before sending.
Sample Prior Authorization Request Letter
Physician’s name
Physician’s address
Physician NPI
Physician’s fax number
Physicians’ office contact
Patient’s name
Patient’s date of birth
Patient’s health plan name and ID#
Dear Sir or Madam:
This is a request for coverage or prior authorization of a weight loss medication for the above named patient
that is indicated for adult patients, who are obese (BMI ≥ 30) or overweight (BMI ≥ 27) WITH a weight-related
comorbid condition. This request is for [drug, dosage, amount, and duration]
Primary Diagnosis
E66.01
Morbid (severe) obesity due to excess calories
E66.09
Other obesity due to excess calories
E66.1
Drug-induced obesity
E66.2
Morbid (severe) obesity with alveolar hypoventilation including pickwickian syndrome
E66.3
Overweight
E66.8
Other obesity
E66.9
Obesity, unspecified, NOS
Note: E66.3 needs to be accompanied with a diagnosis for a weight-related comorbid condition (below)
Secondary Diagnoses
Specific BMI (Some health plans may require the inclusion of a more specific BMI designation)
Z68.27
Z68.28
Z68.29
Z68.30
Z68.31
Z68.32
Z68.33
Z68.34
Z68.35
BMI 27.0 – 27.9
BMI 28.0 – 28.9
BMI 29.0 – 29.9
BMI 30.0 – 30.9
BMI 31.0 – 31.9
BMI 32.0 – 32.9
BMI 33.0 – 33.9
BMI 34.0 – 34.9
BMI 35.0 – 35.9
Z68.36
Z68.37
Z68.38
Z68.39
Z68.41
Z68.42
Z68.43
Z68.44
Z68.45
BMI 36.0 – 36.9
BMI 37.0 – 37.9
BMI 38.0 – 38.9
BMI 39.0 – 39.9
BMI 40.0 – 44.9
BMI 45.0– 49.9
BMI 50 – 59.9
BMI 60.0 – 69.9
BMI 70 or greater
Note: Z68.27, Z68.28, Z68.29 need to be accompanied with a diagnosis for a weight-related comorbid
condition (below)
Weight-Related Comorbid Condition(s) to Support Use of FDA-Approved Medication for Chronic Weight
Management (If applicable, please check any that apply)
E11-E11.9
E78.0
E78.1
G47.33
I10
E78.5
I25.1-I25.119
M15-M19
R73.01
______
Type 2 Diabetes
Hypercholesterolemia
Hyperglyceridemia
Obstructive sleep apnea
Hypertension
Dyslipidemia/Hyperlipidemia
Cardiovascular disease
Osteoarthritis
Impaired fasting glucose
Other
Additional Information
(If applicable, please check any that apply)
S/he has tried and failed to maintain weight loss with the following behavior modification(s):
Diet
Exercise
Other: ______________________________________________________________________
(If applicable, please check any that apply)
This drug is medically necessary because without it this patient is at risk for the following adverse
consequences:
Deterioration of the medical condition with risk of hospitalization, permanent disability, or death
Decline in functional ability
Progression of a chronic disease or disability
Surgical intervention
_________________________________
(If applicable, please check any that apply)
This request meets the following criteria for medical necessity:
The drug will, or is reasonably expected to, reduce or ameliorate the physical, mental, or developmental
effects associated with the illness.
The drug will assist the patient in achieving or maintaining maximum functional capacity in performing daily
activities taking into account both the functional capacity of the individual and those functional capacities that
are appropriate for individuals of the same age.
(If applicable, please check any that apply)
S/he is unable to take the formulary medication/preferred medication because of:
There are no prescription weight loss medications on the formulary
An adverse reaction
A drug-drug interaction
A contraindication
A failure of a therapeutic trial: [specify which formulary alternatives/preferred medications have been tried
and describe results]
___________________________________
Please contact my office should you require any additional information.
Sincerely,
Signature