Cite as: Bolash R. They didn't teach me this in training: successful approaches to denials and peer to peers. ASRA News 2021;46. https://doi.org/10.52211/asra110121.071

The key to success with physician peer to peers for procedural denials was discovered in the 6th century BC, roughly a century before the birth of Hippocrates, who is considered the father of medicine. In that era, Sun Tzu, the Chinese military strategist, gave us the approach when he asserted, “Know thyself; know thy opponent.” With knowledge of the requisite data from the other side’s position, bedside physicians can situate our approach from a position of strength, or more ideally, eliminate peer to peers entirely. I prefer the latter.

Regrettably, approvals for all of the treatments I offer to patients throughout the day do not percolate through my inbox when I open it in the evening. We cannot know the specific details of every patient’s policy, and when I do get a notice, change to the criteria is overdue. Unfavorable decisions are most often delivered in the form of a depersonalized form letter or an e-mail from our authorization team, who has the challenging job of delivering only bad news.

I broadly characterize insurance denials into three buckets: things I haven’t done, things which make little to no clinical sense, and things which make little to no logical sense. The latter two are often related. I’m sure there are other buckets, but let’s tackle the first.

Each year, patients subscribe to a plan or agreement, similar to a contract, with an insurer such as the Centers for Medicare and Medicaid Services or a for-profit entity. The agreement is defined by thousands of pages of terms and requirements: six weeks of physical therapy before an injection, no prescription lidocaine patches prior to failing an over-the-counter strength compound, etc. If I read the denial and recognize that I haven’t ticked the box for a missing bucket, I most often acquiesce and follow the terms of the agreement.

The second two buckets are when I experience the most frustration. “A plain x-ray is required before authorizing magnetic resonance imaging to evaluate nerve root compression.” “An updated computed tomography scan is needed to evaluate whether spinal stenosis is still present; the imaging submitted is a year old.” Although digital radiographs have advanced substantially, I’d challenge anyone who’d suggest that an x-ray is the most ideal imaging study to evaluate neural compression. And in the absence of intervention, spinal stenosis doesn’t reverse or disappear. It takes restraint for me to avoid the response that I want to provide: “You’re most likely going to be looking at the same stenosis this year as last, albeit after an additional 2.5–10 mSV of radiation exposure and another $1,500 expense for the CT scan.”¹

Whereas those situations make little clinical sense, other requirements make little logical sense. “The procedure previously allowable in the prior year is now deemed experimental despite the accumulation of additional favorable evidence over time.” I’d want to read that on a denial one day. The amount of supportive literature has grown over time, yet the established treatment has gained less validity. Genicular interventions come to mind here, though you likely have many other examples.

Despite the challenges, several approaches have facilitated my success in overturning denials.

1. Understand the rationale for denial. Is the therapy deemed experimental? Must the patient have tried and failed other options in advance of the approval? Is the service not part of the benefit package the patient has selected? Each rationale necessitates a divergent negotiation approach. I provide evidence from the contemporary medical literature for experimental treatments, additional history surrounding the rationale to skip steps, and a justifiable argument for a policy exemption (often framed around cost savings or how the condition will deteriorate into higher acuity) for noncovered benefits.
2. Obtain the policy’s specific verbiage. Policy documents are not confidential and can be found on the insurer’s website. With those data, you’re embodying Sun Tzu and approaching the reviewers from a position of strength: knowledge. You’ve read the policy and can cite the information during your conversation.
3. Evaluate the medical director. It’s justifiable to inquire about the reviewer’s specialty at the onset of the call. Reviewing the rationale for an interventional pain procedure with an electrophysiologist will be an entirely different conversation than if the peer to peer is being conducted with a board-certified pain physician. In the former case, I spend more time explaining the pathology and contemporary treatment in a broad overview. For the latter, I highlight how treatment may have evolved since their last bedside contact with patients in the field.
4. Summarize the patient presentation succinctly. Present the patient vignette in two brief sentences with attention to treatments tried and failed. Most importantly, provide your diagnosis. Eliminate all extraneous details that don’t point the medical director directly toward the rationale for the study or therapy you’re requesting be approved.
5. Summarize the treatment and its evidence even more succinctly. Name the diagnostic or requested therapeutic again. Conclude with summative data on the evidence of how your request melds handsomely with the patient’s presentation.
6. Pause. By now you’ve painted a clear picture of the important data. Silence is communication too. Likely a question will follow. Answer it succinctly, and then add in the risks of not obtaining the diagnostic test or administering the therapeutic. Express your interests in a nonadversarial manner.
   

Although I hope that you’re now wrapping up the call by quickly jotting down an authorization number, occasionally a denial is upheld. Maintain collegiality even if that is the outcome. Adversarial provocation will likely only cause the carrier to dig their heels in deeper and perhaps hurt your further chances when you approach the carrier again with your next-level option: a specialty-specific reviewer may be a possibility after a first unsuccessful attempt with a generalist.

Lastly, and although it is often underemphasized, I recommend involving the patient whose care is being denied or delayed. Although we are advocating on each patient’s behalf, policyholders should simultaneously voice their frustrations to the carrier’s consumer arms, regulatory bodies, and their employers. All stakeholders should ultimately hear their voice. Open enrollment occurs each year, and the marketplace is not without choice. If requests are a consistent struggle, the idea to relax stringency or change carriers may percolate. 

Robert Bolash, MD, is an associate professor of anesthesiology in the departments of Pain Management and Medical Operations at Cleveland Clinic in Cleveland, OH.

Reference

Warncke ML, Wiese NJ, Tahir E, et al. Highly reduced-dose CT of the lumbar spine in a human cadaver model. PLoS One 2020;15(10):e0240199. https://doi.org/10.1371/journal.pone.0240199