Critical evidence for prior authorization requests and appeals. Document what was tried, for how long, and why it was not sufficient.
Many insurance plans require patients to "step through" a sequence of treatments before approving a preferred or specialty medication. If this history is not documented, the insurer may deny the request even if the steps were genuinely completed.
Use one row per medication or therapy tried. If steps were completed years ago or with a different provider, include them — and note where records may be obtained.
| Medication / Therapy Tried | Dose | Start Date | End Date | Duration | Reason Stopped / Outcome | Prescribing Provider |
|---|---|---|---|---|---|---|
| Source | Contact / Location | Records Requested? | Received? |
|---|---|---|---|
| Pharmacy medication history printout | Yes No Pending |
Yes No |
|
| Previous provider / clinic | Yes No Pending |
Yes No |
|
| Patient portal (prior system) | Yes No Pending |
Yes No |
|
| Hospital or specialist records | Yes No Pending |
Yes No |
|
| Insurance claims history | Yes No Pending |
Yes No |
