Radiology Prior Authorization and Denial Guide

RBM portal routing through eviCore and AIM Specialty Health, Appropriate Use Criteria and Clinical Decision Support Mechanism documentation requirements, advanced imaging prior authorization criteria, denial patterns for MRI, CT, PET, and nuclear medicine studies, and appeal frameworks grounded in ACR Appropriateness Criteria and operative payer policies. Radiology denial rates average 9–14%, driven primarily by prior authorization denials for advanced imaging.

AUC/CDSM documentation: for Medicare, the Protecting Access to Medicare Act (PAMA) requires that ordering providers consult a qualified CDSM for advanced diagnostic imaging services (MRI, CT, PET, nuclear medicine) before ordering. The CDSM consultation must be documented on the claim. Commercial payers using eviCore or AIM Specialty Health for imaging management require a PA number obtained through the RBM portal before the study is performed — post-service authorization is not available at most commercial payers using these programs.

MRI of the lumbar spine: the highest-volume denied imaging study. Most payers require 4–6 weeks of conservative care failure documentation (physical therapy, chiropractic, or NSAID trial) plus red flag symptoms or neurological deficit for non-emergent lumbar MRI. ACR Appropriateness Criteria for lumbar back pain without red flags rates MRI as "usually not appropriate" within the first 6 weeks. PET scans for oncology require documentation of the specific NCCN-supported indication and prior imaging results. Brain MRI for headache workup requires documentation of progressive, new-onset, or red-flag headache features.

• All specialty guides
• Interventional radiology guide
• Appeal Letter Builder — radiology denial appeals