Prior Authorization for Elective Diagnostic Catheterization: The Value of Reviewers in Cases with Clinical Ambiguity.

Background: In many situations, evidence-based guidelines cannot provide definitive guidance on the appropriateness of diagnostic catheterization. One specialty benefit management company has taken a 2-step approach to address this ambiguity by evaluating the appropriateness of diagnostic catheterization orders using a rule-based decision support system, and then having reviewers provide input through the consult system of a nondenial prior authorization program that involves peer discussion.

Objective: To describe the outcomes of a 2-step approach to evaluating the appropriateness of elective diagnostic catheterization orders.

Method: This program evaluation used data from elective diagnostic catheterization orders from 2015 that pertained to 1 health insurer's Medicare Advantage plans. The classifications of orders by the rule-based system and the approval rates after review by the consult system are presented for these plans. Chi-square tests were conducted to examine whether classifications of the orders by the rule-based and consult systems were independent of plan type, specialty of the ordering physician, or state of residence of the patient.

Results: A total of 3808 orders for elective diagnostic catheterization in 2015 met the inclusion criteria. Inadequate initial justification was provided for 699 (18.4%) of the orders; after inquiry through the consult system, 509 (72.8%) of the remaining orders were approved. Among the 344 (9%) orders that were deemed potentially nonindicated according to the rule-based system, the consult system approved 298 (86.6%). Of the 2765 (72.6%) orders that were deemed potentially appropriate by the rule-based system, the consult system approved 2740 (99.1%). Chi-square tests did not show a significant association between plan type or physician specialty and the classification produced by the rule-based system or the consult system. The patients' state of residence was significantly associated with the classification of orders for the rule-based system ( <.001), but not for the consult system.

Conclusion: Rule-based decision support can be combined with consult-based peer discussion to determine whether care is appropriate when guidelines are ambiguous. Poorly justified orders are often supportable after gathering information on the patient's presentation.