The 5 Most Denied Prior Authorization Requests and How to Prevent These Denials

Robert Neaderthal, MD, MBA

Disclosures

September 17, 2019

RBM guidelines specify that any one of these treatments would meet the criteria, and the treatments can be used in combination or sequentially.

The 6-week timeframe doesn't start when patients first encounter the pain or when they first start taking over-the-counter medications. It only starts when a qualified provider begins treatment. Therefore, the date that a patient starts self-medicating with ibuprofen does not count as the beginning of treatment unless the qualified provider recommended it first.

Also, the physician requesting the MRI does not have to be the same provider who started the regimen. For example, a patient could first visit an urgent care center and be directed to take ibuprofen; 6 weeks later, if there is no improvement, the patient's regular doctor could successfully request the MRI, citing the conservative treatment.

Finally, the conservative therapy must last the full 6 weeks, and at the end, the provider must contact the patient to make sure the pain is still present. This encounter does not have to be an office visit or examination. A phone call or email follow-up will suffice.

Most Denied Request #2: CT Scan to Evaluate Abdominal Pain

A CT scan to evaluate abdominal pain is the second most denied imaging request.

RBM guidelines tend to favor an ultrasound as the initial imaging study, and only then resort to a CT scan if the ultrasound results are inconclusive. The concern is radiation from the CT scan. However, there are exceptions, and depending upon the location of the pain and other symptoms, a CT scan may be the recommended initial test.

For patients with right or left upper quadrant pain, ultrasound of the abdomen should nearly always come first. A CT scan should come first in patients with right or left lower quadrant pain because ultrasound has not proven to be useful in these cases.

Children and women of childbearing age should almost always get an ultrasound first due to the radiation exposure of a CT scan.

The choice to use an ultrasound first also depends on the type of pain. For example, diffuse mild or moderate periumbilical pain should be evaluated with an ultrasound of the abdomen and pelvis before subjecting a patient to a CT scan.

Use of contrast material with the CT scan is also an issue to consider. In most cases, the guidelines call for contrast, but in some cases—such as a patient with a suspected kidney stone or adrenal nodule—a CT scan without contrast is recommended. A dual study, without and with contrast, is rarely indicated. The instances when it is indicated are outlined in the RBM guidelines. Physicians may refer to RBM guidelines to make sure the PAL is asking for the preferred CT scan.

As with MRI guidelines of the lumbar spine, there are red flag signs that allow the patient to go directly to receiving a CT scan. These include fever, elevated white blood cell count, a mass, gastrointestinal bleeding, moderate to severe tenderness, guarding or rebound tenderness, history of cancer, and a past history of bariatric surgery.

Only one of these signs is needed to obtain approval of a CT scan, and the specific abdominal location does not matter. When your PAL tells the RBM nurse there is a red flag, your request will likely sail through.

Most Denied Request #3: CT Scan of the Chest

The third most commonly denied imaging study for primary care physicians is a CT scan of the chest.

One common mistake is to request [a CT scan] before ordering a plain chest x-ray.

One common mistake is to request this study before ordering a plain chest x-ray. The request will also typically be denied if the x-ray had been performed but was not reported to the RBM nurse when the request was made.

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