Patient
K.L. (de-identified)
PA-98220 Prior Auth Detail
LYA-Immuno 2 | Aetna | Status: Additional Docs Requested
Next action: Upload prior history notes
Policy: Aetna specialty policy SP-224 (revised Jan 2026)
Patient and Case Context
De-identified snapshot used to justify authorization request.
Diagnosis
Moderate-severe autoimmune disease, refractory to prior therapy
Requested start
Within 7 days to avoid treatment gap
Benefit type
Commercial, pharmacy benefit
PA Checklist and Documents
Submission-readiness controls to prevent avoidable rework.
Most recent progress note
Status: Attached
Source: EHR visit 2026-02-18
Prior therapy history
Status: Attached
Source: Medication history export
Lab panel summary
Status: Attached
Source: Lab report 2026-02-14
Detailed stop reason letter
Status: Missing
Source: Provider attestation pending
Payer Criteria Mapping
Explicit mapping of policy criteria to supporting evidence.
Confirmed on-label diagnosis
Status: Met
Evidence: Specialist note and coding present
Step therapy requirement
Status: Met
Evidence: Two prior regimens documented
Clinical severity threshold
Status: Met
Evidence: Disease activity score in latest note
Discontinuation rationale for prior therapy
Status: Needs Evidence
Evidence: Need signed stop-reason addendum
Denial Risk Signals
- Missing signed discontinuation rationale
- Potential mismatch between payer preferred template and clinic narrative format
Timeline
Submission and rework events across this PA case.
Case created
2026-02-15
Complete
Initial packet sent
2026-02-16
Complete
Payer ADR request
2026-02-19
Received
ADR resubmission
2026-02-24
In progress
Communication Log
Payer, field, and office touchpoints tied to this authorization.
Payer portal
Owner: Reimbursement specialist
ADR request cites missing discontinuation reason.
Field reimbursement
Owner: Lya FRM
Provided payer-specific template and wording guidance.
Provider office
Owner: Nurse coordinator
Awaiting provider signature by end of day.
Add / Correct Information
Click to append missing details and approval-ready notes.
Add Missing Document Detail
Capture missing evidence and assignment for completion.
Add Payer Follow-up Outcome
Document call outcomes and required next actions.