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

Robert Neaderthal, MD, MBA

Disclosures

September 17, 2019

There are a few exceptions when a chest x-ray is not required, such as for lung cancer screening when a CT scan is used. However, the patient must meet every one of the guideline criteria, which include a detailed smoking history of at least 30 pack-years (cigarette packs smoked per day multiplied by the number of years a person has smoked) or having smoked within the past 15 years.

Additionally, the patient must be 55-80 years old, must not be too debilitated to have major lung surgery, and the scan cannot be repeated within the past 12 months.

Asking for a contrast study often results in denials of CT scans of the chest. Contrast material in a CT scan should not be used to screen for lung cancer, follow a solitary pulmonary nodule for change in size, or evaluate or monitor interstitial lung disease. All other reasons for a chest CT scan would support using contrast.

Asking for the wrong CT scan can also result in a denial. Some physicians are unsure whether to use a CT scan with contrast, without contrast, or with and without contrast (a dual study). To be safe, these physicians often request the dual study.

However, a dual study exposes the patient to twice the radiation of one study. The American College of Radiology guidelines state that a dual study of the chest is almost never needed.

Another common reason for requesting a chest CT scan is to follow up on a previously discovered solitary pulmonary nodule. Most RBMs use the Fleischner Society criteria, which determine the frequency and duration of the CT scan based on the size and nature of the nodule.

These criteria are readily available in guidelines on RBM websites and should be read and followed carefully before requesting a CT scan.

Most Denied Request #4: Choosing Diagnostic Tests for Coronary Artery Disease

The fourth most common denial for primary care physicians and the number one denial for cardiologists are diagnostic tests for coronary artery disease (CAD). This guideline can be quite complicated, so if you are not paying close attention, you can easily get it wrong.

Physicians often see patients with a recent history of chest pain, requiring them to rule out CAD. Under RBM guidelines, the type of test used to screen these patients depends on the type of pain they present with—acute pain, typical cardiac pain, atypical pain, or nonanginal pain.

For acute pain, recommended tests include sestamibi myocardial perfusion imaging (sestamibi MPI), stress echocardiography (stress echo), or immediate cardiac catheterization.

For previously undiagnosed chronic or intermittent chest pain, there is a choice of three diagnostic tests, depending upon the clinical presentation—a nonimaging exercise treadmill test (ETT), stress echo, or sestamibi MPI.

Although ETT does not require prior authorization, sestamibi MPI almost always requires prior authorization, and stress echo requires approval for some insurance companies but not all.

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