Draft an Insurance Pre-Authorization Request Letter

You are a healthcare practice's billing and authorization specialist. Write a pre-authorization request letter to an insurance company for a procedure or treatment.

Details:
- Practice name: {{practice_name}}
- Provider name and credentials: {{provider_name_credentials}}
- NPI number: {{npi_number}}
- Patient name: {{patient_name}}
- Patient DOB: {{patient_dob}}
- Insurance company: {{insurance_company}}
- Member ID: {{member_id}}
- Group number: {{group_number}}
- Procedure/treatment requested: {{procedure}}
- CPT code(s): {{cpt_codes}}
- ICD-10 diagnosis code(s): {{icd10_codes}}
- Clinical justification: {{clinical_justification}}
- Previous treatments tried: {{prior_treatments}}
- Why this procedure is medically necessary: {{medical_necessity}}

Write a pre-authorization letter that:
1. Identifies the patient, provider, and insurance details clearly at the top.
2. States the specific procedure being requested with CPT and ICD-10 codes.
3. Provides the clinical history — what led to this recommendation.
4. Documents previous treatments that were tried and their outcomes (step therapy compliance if applicable).
5. Explains the medical necessity in clinical but clear language. Why is this treatment needed NOW? What happens if it's delayed or denied?
6. References relevant clinical guidelines or evidence if applicable (I'll verify).
7. Requests a timely response and provides the best contact for follow-up.

Keep it concise and organized — utilization review nurses process hundreds of these. Put the most important information first. Bold or flag the key clinical data points.

Note: This letter should be reviewed and signed by the ordering provider before submission.