How to Nail a Medication Prior Authorization

I am sure you have received the dreaded bounce back from a medication prior authorization.
We have all experienced that frustration. We know the patient needs it, the provider took the
time to prescribe, BUT, the insurance company wants to slow things down with an extra layer of
justification.

It’s not always about the cost of the drug, although we know that is a part of the equation.
Ultimately, it comes down to how well you tell the story behind why this patient needs that
medication now.

And when it comes to specialty medications or drugs that require step therapy documentation,
missing just one piece of that story can mean an unnecessary delay or outright denial.

Let’s walk through how to make your medication PAs clear and concise, and how to stop writing
the same justification over and over again from scratch.

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Why Medication PAs Get Denied So Easily

Medications get denied for a few common, but, predictable reasons:

• The provider didn’t list the patient’s prior treatment failures.
• No documentation was included to show why first-line therapies weren’t appropriate and/or effective.
• Diagnosis codes were too vague or didn’t match the approved indications of use.
• The patient is off-label, and no rationale or supporting evidence was included.

It can be frustrating, as many of these things are in the patient’s chart. They’re just not spelled
out clearly or detailed enough to satisfy the reviewer who has roughly 90 to 120 seconds to
decide whether to approve or deny your request.

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Let’s Use a Real Example: A GLP-1 Agonist

Let’s say you’re prescribing semaglutide (Ozempic or Wegovy). Whether it’s for diabetes or
weight management, here’s what the payer is going to look for:

• Exact diagnosis (e.g., Type 2 Diabetes Mellitus with hyperglycemia, not just “DM2”)
• BMI documentation with date and exact number
• HbA1c value with recent lab result
• Failed medications: which ones, how long they were tried, and what the outcome was
• Lifestyle interventions attempted and documented
• Why other medications aren’t appropriate: side effects, contraindications, or lack of efficacy

Even if all of that’s in the chart, unless it’s clearly outlined in the prior auth request, or attached
in a supporting note or letter, to the reviewer, it does not exist.

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The Format Matters: Narrative + Data

The best medication PA is a hybrid. It should blend clinical data with a narrative that shows
decision-making.

Here’s a solid structure:

1. Start With the Diagnosis and Baseline
   “Mr X is a 44 year old male with Type 2 diabetes. He was diagnosed in 2017. His most recent HbA1C was 8.9% (Drawn 3/12/25). BMI is 37.7”

2. List Previous Treatments and Outcomes
   “Trialed metformin and glipizide for 9 months. Despite adherence, HbA1c remained >8%. Patient experienced GI side effects with metformin: no significant improvement with glipizide”

3. Add Non-Pharmacological Interventions
   “Completed 12-week nutrition counseling and weight management program through primary care. Modest weight loss achieved, but glycemic control remain suboptimal”

4. State Why This Medication is Needed Now
   “Semaglutide is indicated based on current guidelines and patient’s clinical profile. Its dual impact on glycemic control and weight reduction makes it the most effective next step intervention”

If you’re attaching a note/letter instead, make sure it includes this information, or create a quick
Letter of Medical Necessity using the same structure. Leverage FightPaperwork to ensure you
have all the necessary documentation for an approval.

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Common Mistakes That Cause Headaches

• Using an incomplete diagnosis code (e.g., E11 instead of E11.65)
• Failing to include dates of treatment trials to show pattern
• Leaving out the reason a previous med was stopped
• Submitting just the prescription without any documentation of need
• Not updating labs or vitals when the last visit was more than 30 days old

These mistakes don’t just slow things down, they often lead to a hard denial that takes even
more time to appeal the decision.

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How FightPaperwork.com Simplifies the Process

Medication PAs are repetitive. The story changes slightly, but the structure rarely does. That’s
where FightPaperwork.com gives you the upper hand.

You can:

• Answer guided questions that help you include all necessary details.
• Automatically generate a properly formatted letter or medical note based on your responses.
• Save and reuse templates for different drug classes or insurance plans.
• Attach recent labs and notes without toggling between systems.
• Track denial reasons and appeals so you’re not repeating errors.

Instead of rewriting the wheel every time a GLP-1, ADHD med, or inhaler needs authorization,
you start with a solid framework, and only have to make minor changes to those things that are
clinically relevant.

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Quick Reference: What to Always Include in a Medication PA

• Diagnosis + ICD-10: Use the most specific, supported code
• Treatment history: Include drug name, duration, and outcome
• Contraindications: Note adverse reactions or failures
• Recent labs/vitals: Especially for chronic conditions
• Narrative rationale: Show why this drug is clinically necessary

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Final Thoughts

Medication PAs don’t have to be a game of chance. The difference between approval and denial
often comes down to how well you tell the story of your patient's medication needs. It requires
you to have the right pieces of evidence front and center.

If you’re tired of getting stuck in the same cycle of resubmissions and back-and-forth with the
pharmacy, it might be time to tighten your process and let a platform like FightPaperwork.com
do some of the heavy lifting. Spend more time delivering healthcare not defending it.

Danielle Miller, RN
Doctorate-Level Nursing Expert | Healthcare Consultant | Academic Advisor