Why Imaging Requires Prior Authorization
Advanced imaging (MRI, CT, PET scans) frequently requires prior authorization because of their high cost and potential for overutilization. Insurers use prior authorization to ensure imaging is medically necessary before approving expensive scans. However, unnecessary delays in imaging can postpone diagnosis of serious conditions.
Imaging authorization typically focuses on medical necessity: Is the imaging appropriate for the clinical question being asked? Are there less expensive alternatives that would answer the same clinical question first? Is the imaging supported by clinical guidelines for this indication?
Common Imaging Authorization Requirements
MRI of the Spine: Often requires documentation of failed conservative treatment (physical therapy, medication), imaging or clinical evidence of potential structural abnormality, and functional limitation. Cost limits authorization on many plans.
CT of the Abdomen/Pelvis: Usually requires documentation of specific clinical indication, prior imaging if applicable, and symptoms or findings suggesting the need for imaging.
PET Scan: Frequently requires oncology consultation documentation, prior standard imaging, and clinical staging information. Medicare and many insurers limit PET approval to specific cancer types and scenarios.
Fighting Imaging Denials
If your imaging is denied, your healthcare provider should request clinical review by a radiologist. Provide comprehensive clinical documentation supporting why standard imaging is insufficient and why advanced imaging is necessary. Document any prior imaging and why it was inconclusive.
If step therapy is the denial reason (your plan requires X-ray before MRI), request an exception by demonstrating that step therapy is not appropriate for your clinical presentation.
Getting Authorization Quickly
Obtain prior authorization before scheduling imaging whenever possible. Ask your healthcare provider's office to submit the authorization request and follow up within 24 hours if not approved. If your condition is urgent (acute neurological symptoms, trauma), request expedited processing.