Archives

Most prior authorization denials are decided well before the request is sent. These six cases show where they start and what stops them. Key Takeaways Every case in this series turned on one [...]

The note said “several weeks” of back pain. The reviewer needed dates. Key Takeaways Advanced spine imaging is one of the most common places a request stalls on conservative care [...]

Two pages of notes, one vague phrase, and an office visit from seven months ago. Key Takeaways Payer reviewers match the documented diagnosis to the policy. A general symptom rarely matches. An [...]

The clinicals were fine. The formulary was the problem. Key Takeaways Branded drugs often sit behind step therapy. This patient’s plan wanted a preferred alternative tried first. Checking [...]

The patient responded well to every injection. The chart never said where the series was going. Key Takeaways Some payers expect facet injections to lead somewhere: usually radiofrequency [...]

Sometimes the most valuable prior authorization is the one you never send. Key Takeaways Some denials are written into federal law. No amount of documentation or appeals can change them. Drugs [...]

The clinicals can be perfect. If the rendering provider is out of network, the HMO answer is still no. Key Takeaways On HMO and EPO plans, network status can decide a request before anyone reads [...]