Harrer Samantha, Hedden Kathryn, Mikaeili Sadegh, Bazrafshan Nazila, Gentile Pietro M, Gealt David B, Brown Matthew L
From the Department of Orthopaedic Surgery (Harrer, Hedden, Gentile, Gealt, and Brown), Department of Orthopaedic Surgery, Cooper University Health Care, and the Cooper University Health Care (Mikaeili and Bazrafshan), Camden, NJ.
J Am Acad Orthop Surg. 2025 Feb 15;33(4):e244-e252. doi: 10.5435/JAAOS-D-24-00442. Epub 2024 Dec 27.
Magnetic resonance imaging (MRI) has revolutionized musculoskeletal care. However, its high costs and high utilization has prompted many insurance payors to require a prior authorization. This process remains burdensome and results in delays to patient care. The purpose of this study was to examine the relationship between several variables and the denial rate of outpatient MRI prior authorization requests from a single institution's department of orthopaedics.
MRI prior authorization insurance data was retrospectively collected from January 2019 to December 2022. Patient demographics, imaging characteristics, and insurance details were extracted and stratified into generalized categories. Analysis of variance, multivariate logistic regression models, and odds ratios (ORs) were used to predict the likelihood of request denial with α = 0.05.
Of the 17,913 total MRI prior authorization requests identified, 885 (4.94%) were denied. Race and socioeconomic status were not markedly different between the authorized and denied cohorts; however, primary insurance payor, chief symptom, and anatomic location to be imaged were found to have notable differences between authorized and denied cohorts ( P < 0.0001). MRIs of the spine were less likely to be authorized compared with the shoulder (OR 0.51), upper extremity (OR 0.43), knee (OR 0.38), lower extremity (OR 0.34), and foot and ankle (OR 0.75) with P < 0.02 for each. Horizon NJ Health and Horizon Blue Cross Blue Shield, both Medicaid payors, were also less likely to authorize requests compared with other payors (Aetna, OR 0.37 and United Healthcare, OR 0.36) ( P < 0.01 for both).
The low denial rate of initial prior authorization requests over 4 years at our institution underscores the questionable utility of the prior authorization process. Our results are consistent with the current literature that has reported higher rates of denials for MRI prior authorization requests of the spine. Although we were not able to quantify the effect of these denials on patient care, the overall time required to process these requests undoubtedly causes delays in patient care. despite no notable difference seen in socioeconomic status, Horizon NJ Health, a major provider of only Medicaid insurance plans at our institution, was associated with a higher likelihood of denial. This suggests that MRI prior authorization requests submitted for Medicaid patients are more likely to be denied and cause an inequitable delay in care due to this process.
磁共振成像（MRI）彻底改变了肌肉骨骼疾病的治疗方式。然而，其高昂的成本和高利用率促使许多保险支付方要求进行事先授权。这个过程仍然繁琐，导致患者治疗延迟。本研究的目的是探讨几个变量与单一机构骨科门诊MRI事先授权申请被拒率之间的关系。
回顾性收集2019年1月至2022年12月的MRI事先授权保险数据。提取患者人口统计学信息、影像特征和保险细节，并将其分层为一般类别。采用方差分析、多变量逻辑回归模型和比值比（OR）来预测申请被拒的可能性，α = 0.05。
在总共17913份MRI事先授权申请中，885份（4.94%）被拒。获批和被拒队列之间的种族和社会经济地位没有明显差异；然而，主要保险支付方、主要症状和拟成像的解剖部位在获批和被拒队列之间存在显著差异（P < 0.0001）。与肩部（OR 0.51）、上肢（OR 0.43）、膝盖（OR 0.38）、下肢（OR 0.34）以及足踝部（OR 0.75）相比，脊柱MRI获批的可能性较小，每项的P均< 0.02。新泽西州医疗保健计划（Horizon NJ Health）和新泽西蓝十字蓝盾公司（Horizon Blue Cross Blue Shield）均为医疗补助支付方，与其他支付方（安泰保险，OR 0.37；联合健康集团，OR 0.36）相比，它们批准申请的可能性也较小（两者的P均< 0.01）。
我们机构4年来初始事先授权申请的低拒签率凸显了事先授权过程的效用存疑。我们的结果与当前文献一致，文献报道脊柱MRI事先授权申请的拒签率较高。尽管我们无法量化这些拒签对患者治疗的影响，但处理这些申请所需的总体时间无疑会导致患者治疗延迟。尽管在社会经济地位方面没有明显差异，但新泽西州医疗保健计划是我们机构仅提供医疗补助保险计划的主要机构，其申请被拒的可能性更高。这表明为医疗补助患者提交的MRI事先授权申请更有可能被拒，并且由于这个过程会导致不公平的治疗延迟。
