PA-2025-001
Case submitted: October 6, 2025
The payer has determined this request does not meet medical necessity requirements because:
Documentation does not show sufficient trial of standard therapies
Functional improvement or outcome measures not provided
Diagnosis does not align with covered indications
Supporting clinical notes are incomplete or missing
You have 29 days left to appeal
To start an appeal, update the information listed on your denial checklist to the left, and then click the "Start Appeal" button below.
Start Appeal
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