Magnetic Resonance Imaging Prior Authorizations for Orthopaedic Care Are Negatively Affected by Medicaid Insurance...

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.