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

Robert Neaderthal, MD, MBA

Disclosures

September 17, 2019

Virtually all requests must be accompanied by the results of a standard x-ray taken since the injury. If the MRI is requested for chronic pain, the x-ray must be made in the past 3 months.

As in several other guidelines, this guideline first requires 6 weeks of conservative treatments that have not been successful, including:

  • Physical therapy;

  • Analgesic agents, such as NSAIDs, injections, or stronger pain medications;

  • Chiropractic treatment;

  • A provider-directed home exercise program; or

  • Use of medical devices, such as splints, crutches, and braces.

The 6 weeks begins when any doctor or other qualified provider begins treatment.

The RBM guideline also lists many exceptions where the 6 weeks of conservative therapy can be skipped, such as:

  • For MRI of the shoulder: suspected postfall acute rotator cuff injury, labral tear, suspected delayed union or nonunion of a fracture, avascular necrosis, tendon rupture, suspected osteomyelitis, tumor, or planned surgery; or

  • For MRI of the knee: suspected meniscus tear, complex fracture, suspected delayed union or nonunion of a fracture, avascular necrosis, patella dislocation, tendon rupture, suspected osteomyelitis, tumor, or planned surgery.

Other exceptions are listed in the guidelines published by RBMs.

Conclusions

Although RBM guidelines are substantially shorter than the original medical society guidelines, they still contain many nuances and must be reviewed carefully to be fully understood.

Find the guidelines on RBM websites, download them onto your own computer, and consult them whenever you are uncertain.

Find the guidelines on RBM websites, download them onto your computer, and consult them whenever you are uncertain about how to proceed.

In addition, you must communicate well with your PALs, and they must communicate well with the RBM nurse. For example, if your patient has had a required x-ray, but it does not get reported to the RBM nurse, the request will be denied.

This extra work is well worth the effort. It will spare you a great deal of anguish when your request is denied and you have to reschedule appointments with patients, undertake an appeal, and, in many cases, conduct a peer-to-peer phone call with an RBM medical director to explain your request.

Editor's Note: This article features additional reporting by Leigh Page.

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