Establishing medical necessity may be a critical component in the prior authorization process for private payers. Payers will likely want to understand the nature of the drug, why it has been recommended and is appropriate for the patient, and the treatment history of the patient.

Letter of Medical Necessity
	Description: Letters of Medical Necessity provide an explanation of why PRIALT is appropriate for the patient. Download: Example letter of medical necessity form (36kb pdf)

The following information should accompany all prior authorization requests and final claim submissions:

• Letter from the physician describing why PRIALT is appropriate for the patient and/or why the current treatment approach is no longer a viable option
  
  
• The risks to the patient of foregoing therapy with PRIALT
  
  

• Patient Symptoms

  • Review patient's chart notes to determine if the following exists:
    
    
    • Severe chronic pain in patients for whom IT therapy is warranted, and who are intolerant of or refractory to other treatment, such as systemic analgesics, adjunctive therapies or IT morphine
      
      
    • Patient complaints and/or side effects with opioid-like complications, such as respiratory depression, tolerance, drug dependence and signs of withdrawal
      
      

• Treatment History
  
  

  • List all therapies previously prescribed for managing the patient's symptoms
    
    
  • Provide patient chart notes to document previously attempted therapies for managing the patient's condition
    
    

• Pain Intensity Test Results and Physician Assessment of Opioid Risk/Complications
  
  

  • Provide Visual Analog Scale of Pain Intensity (VASPI) scores or other pain measurement scores, if available
    
    
  • Include physician exam notes or observations of respiratory depression, tolerance, drug dependence and signs of withdrawal, caused by opioid-like complications