Editor's Note: Robert Neaderthal, MD, MBA, an internist in Nashville, Tennessee, worked as medical director of a radiology benefits management company after practicing for 30 years. During that time, he reviewed procedure requests sent to insurers. Based on that experience, he saw what physicians did wrong that ended up with requests denied, and he tells physicians how to do it right.
When it comes to prior authorizations for imaging studies, there are five specific requests that incur the greatest number of denials.
When physicians' requests are denied, it's often because they don't understand nuances in the guidelines used by radiology benefits management (RBM) companies that review requests for the payer. This can lead to a lot of exasperation and wasted time.
By reviewing these five examples, you can also get a general idea of the thinking process needed to get approval for any request.
Nothing takes the place of carefully reading RBM guidelines, which are on RBM company websites. These guidelines closely follow the established guidelines published by specialty medical societies, but they are shorter and easier to search.
Most Denied Request #1: MRI of the Lumbar Spine
More requests for MRI of the lumbar spine are denied than any other imaging study. They are almost always denied for one of two reasons:
Lack of a "red flag" symptom or other sign in the patient, which would allow for immediate approval; or
Lack of 6 weeks of unsuccessful conservative therapy directed by a provider—the usual way to get approval.
Most physicians know a few of the red flag signs, such as leg weakness and cauda equina syndrome, a fairly rare disorder involving spinal nerve compression.
Lesser-known red flags include suspected infection, fever, diabetes, patients older than 70 years, any immune-compromised state, intravenous drug use, a suspected vertebral fracture with low bone density, night pain, pain unrelieved with position change, and unexplained weight loss.
If your staff member who deals with authorization requests, identified here as the prior authorization liaison (PAL), tells the RBM nurse that your patient meets any one of these red flag signs, the MRI request will be approved immediately.
However, most patients with low back pain do not have any red flag signs, so the RBM review is based on the alternative—whether or not there were six full weeks of provider-directed conservative care. Not meeting this timeframe is the most common reason for denial.
Physicians and other qualified providers often misunderstand what constitutes conservative care and when the 6-week timeframe starts. (Qualified providers include a physician, physician assistant, nurse practitioner, or chiropractor.)
Conservative care may include physical therapy; use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen; other pain medicines such as short-term narcotic agents or gabapentin; home exercise programs; chiropractic manipulation; and even observation of the patient without any medicines by the physician or other qualified provider.
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Cite this: The 5 Most Denied Prior Authorization Requests and How to Prevent These Denials - Medscape - Sep 17, 2019.