PA-2025-001
Case submitted: October 6, 2025
Patient Information
Full Name:
Smith, Janice
Date of Birth:
April 30, 1970
MRN Number:
12345
Phone Number:
(760) 937-5480
Address:
2230 Hessler Blvd
New Castle, DE 19720
Photo ID:
Primary Insurance Coverage
Insurance Plan:
Blue Cross Blue Shield
Member ID:
BC987654321
Eligibility:
Verified
Verification Method:
Payor portal
Insurance Card:
Ordering Provider
Provider Name:
Dr. Michael Chen
NPI Number:
0987654321
Specialty:
Pulmonology
Contact:
mchen@pulmocare.com
TIN:
12-3456789
PTAN:
0012345
Facility Information
Facility Name:
Beebe Healthcare
Facility NPI:
0012345
TIN:
12-3456789
Address:
424 Savannah Rd
Lewes, DE 19958
Device/Service
HCPCS/CPT Code:
E0470
Device Model:
ResMed AirSense 10
Manufacturer:
ResMed
Place of Service:
Home
Request Urgency:
Routine
Diagnosis Codes
Primary ICD-10 Code:
G47.33
Secondary ICD-10 Codes:
N/A
Letter of Medical Necessity
Blue Cross Blue Shield
1234 Ranch Rd
San Diego, CA 92102
(760) 937-5480
Member name: Janice Smith
Member date of birth: April 30, 1970
Subscriber number: 12345
Group number: 6789
Request for approval of BRUKINSA (zanubrutinib)
Dear Mr. Kingsley,
I am writing to request prior authorization/document medical necessity for my patient, Janice Smith. I have prescribed BRUKINSA as a treatment for C83.1. This letter provides details of the patient’s medical history and rationale for treatment.
Patient’s medical history:
[Provide brief clinical description of patient, rationale for using BRUKINSA, and treatment history. List all current and past therapies.]
Thank you for your consideration of this request. I look forward to your prompt review.
Sincerely,
Dr. Jerald Wilson
0919-BRU-PRC-007