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

Robert Neaderthal, MD, MBA

Disclosures

September 17, 2019

The optimal test depends on the patient's pretest probability (PTP) for CAD. Calculating PTP is an approximation based on age, sex, and description of the type of pain.

Guidelines from national cardiology organizations support a traditional ETT in a few well-defined circumstances. It should be performed as the first test if the patient:

  • Has a low PTP for CAD (also called nonanginal chest pain);

  • Is physically able to walk on a treadmill; and

  • Has an ECG that is interpretable and does not show left bundle-branch block, paced rhythm, ST-segment depression, or preexcitation.

If the ETT results are normal, the likelihood of CAD is very low, and no additional testing is necessary.

Similarly, if patient presents with atypical chest pain, an ETT may also be the initial study, and if the ETT results are negative, additional testing may not be needed.

However, patients with a high probability of CAD should skip the ETT and go directly to an advanced imaging study—either stress echo or sestamibi MPI.

RBM guidelines include some clinical exceptions that may warrant an imaging test in lieu of an ETT. For example, patients should skip the ETT if they have had a previously diagnosed or definite CAD, or if they have had a myocardial infarction, stent, bypass, or past positive result on catheterization. Instead, they should be evaluated with a stress echo or sestamibi MPI.

Patients can skip the ETT and go directly to an imaging scan if they are older than 40 years and have chest pain plus diabetes, or if they have a coronary artery calcium score over 100. Other criteria and exceptions may be found in RBM guidelines for CAD imaging.

Most imaging study denials for diagnosing CAD involve patients with low or intermediate PTP, and the denial reason will specify that an ETT should be performed before an advanced imaging study.

Most Denied Request #5: MRI of the Shoulder or Knee

Denials of an MRI of the shoulder or knee usually have to do with lack of a recent x-ray or not completing 6 weeks of unsuccessful conservative treatment directed by a qualified provider.

This rationale is often misunderstood, so breaking down each subtle component can help you avoid many imaging study denials.

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