Structured Medical Report for Health Insurance Authorization

Create a structured medical report template for requesting authorization of the procedure [PROCEDURE] (TUSS code: [TUSS_CODE]) from health insurance carriers, following ANS requirements.

**1) IDENTIFICATION:**
- Patient: [PATIENT NAME], CPF [CPF_NUMBER], member ID [MEMBER_ID]
- Insurance carrier: [INSURANCE_CARRIER] — ANS registration: [ANS_NUMBER]
- Requesting physician: Dr. [PHYSICIAN_NAME], CRM [CRM_NUMBER]/[STATE], RQE [RQE_NUMBER]
- Facility CNES: [CNES]
- Request date: [DATE]

**2) CLINICAL JUSTIFICATION (SOAP format):**
- **S (Subjective):** Chief complaint, history of present illness, symptom duration
- **O (Objective):** Relevant physical exam, complementary test results with dates
- **A (Assessment):** Primary ICD-10: [PRIMARY_ICD] and secondary: [SECONDARY_ICDS]
- **P (Plan):** Requested procedure with technical justification

**3) PREVIOUS TREATMENTS:**
- Conservative treatment attempted (type, duration, outcome)
- Medications used without adequate response
- Other procedures already performed
- Justification of therapeutic failure

**4) TECHNICAL-SCIENTIFIC RATIONALE:**
- Clinical protocol from the specialty society
- Applicable ANS guideline
- Bibliographic references (1-2 recent articles)
- Nature: elective / urgent / emergency

**5) REQUIRED SUPPLEMENTARY MATERIALS:**
- List of attached exams with results
- Clinical photos when applicable
- Medical board opinion (if required)

**6) COMMON ERRORS THAT CAUSE DENIAL:**
- List of the 10 most frequent errors in [SPECIALTY] reports
- Fields commonly overlooked by carriers
- Tips for filling in [BRACKETS]

Format: precise technical language, no non-standard abbreviations. Include version for SUS referral via SISREG.