What’s Broken, What Works, and How to Protect Your Practice
The Reality of Prior Authorization for IR Procedures
Prior authorizations for Interventional Radiology (IR) procedures remains unpredictable. Payers frequently outsource reviews to TPAs such as eviCore, AIM, or Carelon – often switching without notice. Rules vary by plan, and reviewers are often non-specialists. It is common for an OB/GYN or family physician to determine medical necessity for complex vascular or embolization cases.
The “No Auth Required” Illusion
When a payer says “no authorization required” it seldom guarantees payment. It may mean:
- The carrier won’t review before the procedure but can still deny afterward.
- The service is not a covered benefit for the patient’s plan.
- The procedure is labeled “experimental” or ‘investigational” – a label frequently applied to accepted or emerging IR therapies like embolization for osteoarthritis are often non-covered by the carrier.
Best Practice
Ask WHY no prior auth is required.
- Is it not a member benefit, plan benefit, never covered, experimental, investigational?
- Document the name, date, and reference number of the representative confirming “no auth required.”
- Include full medical necessity rationale, even if prior auth is not required.
- Keep screenshots or portal confirmations.
- Remember: “No auth required” shifts the burden to you – documentation becomes your only defense.
ICD-10 and CPT®: The Core of Medical Necessity
Accurate indication and diagnosis coding are at the heart of medical necessity. Consistent documentation of signs and symptoms are as important as the diagnosis itself—they work together to justify the procedure and ensure reimbursement across all carriers with medical-necessity policies.
Carriers determine medical necessity by matching ICD-10-CM diagnosis codes to the policy-approved indications for the billed CPT® procedures. The primary diagnosis or indication must clearly explain why the exam or intervention was needed. Clinic notes should support this.
Best Practice
- Always include signs, symptoms, and failed conservative management (e.g., claudication, non-healing ulcer, hematuria, pelvic pain) in your documentation.
- Avoid vague or “rule-out” terms – use definitive, clinically supported language aligned with LCDs, NCDs, and payer medical-necessity policies.
- If documentation lacks precision, coding may result in different than codes approved for prior auth resulting in a valid procedure being denied as “not medically necessary”.
Requesting All CPT® Possibilities: Why IR is Different
In IR, the full procedural pathway is often unknown until the case begins. Unlike open surgery, IR procedures are dynamic and adaptable based on findings during the procedure.
Because of this variability, always request authorization for all CPT® codes that could reasonably occur during the planned intervention.
Best Practice
- Submit the entire expected CPT® range based on potential findings (e.g., diagnostic angiography, atherectomy, stent, embolization).
- Include a clear explanation – “Therapeutic escalation may be required based on angiographic findings.”
- Clinic notes should support medical necessity.
- If payer portals reject multiple CPTs, attach a written rationale or contact the payer directly.
- Keep records of all requested CPTs and the representative’s confirmation or portal response.
Average Turnaround Times
|
Step |
Typical Bus Days | Notes |
|
Initial Submission |
2-5 |
Longer for vascular, oncology cases |
|
Add’l Documentation |
+2-7 |
Common for PAD, Dialysis, Embolization |
|
Peer-to-Peer |
+2-5 |
Delays due to reviewer availability |
| Appeal/Reconsideration | +5-15 |
Adds weeks if escalated |
- Carriers quote a total average timeframe of 7 – 14 business days; however, documentation clearly supporting medical necessity typically takes 7-10 days.
- Urgent cases typically take 72 hours if carrier’s criteria are met.
Urgent Requests: When “Urgent” Isn’t Urgent
Physicians often mark cases as urgent when delay could cause harm—acute ischemia, hemorrhage, or infection. But carriers apply internal “urgent” criteria that are inconsistently enforced and rarely public.
Best Practice
- Document Why a prior auth delay poses harm using clear, clinical language.
- Include imaging, wound findings, and objective data.
- Cite professional guidelines (SIR, SVS, ACR, OEIS).
- Track all case numbers, reps, and denial notes.
Documentation is the Differentiator
Prior Auth success hinges on structured, evidence-based documentation that demonstrates adherence to the standard of care.
Best Practice
- Conservative therapies tried or contraindicated – document it.
- Clear rationale when tests (e.g., ABI) weren’t performed – document it.
- Literature and guidelines supporting medical necessity – document it.
- Summaries of prior imaging and interventions – document it.
- Explanations for omitted tests or atypical approaches – document it.
Reducing the Burden: Outsourced Pre-Auth Services
Many IR practices now use third-party prior auth services to offload administrative work. Example: StreamlineMD handles eligibility checks, submissions, peer-to-peer coordination, and tracking—allowing providers to focus on patient care.
Such services:
- Monitor payer and TPA policy changes.
- Handle multi-portal submissions and communications.
- Provide turnaround-time and denial reports.
- Outsourcing can reduce burnout, missed deadlines, and denials, particularly for high-volume IR practices.
Note: Be skeptical of vendors offering AI solutions for prior auths. StreamlineMD is a consumer of AI automation, and continuously evaluates AI solutions that are viable and make sense to include in our service platform. To date, the prior auth AI solutions we’ve seen and tested are not ready for prime time for IR purposes. If you see a solid demonstration and talk to other IR practices that use the AI solution with a high level of satisfaction, please contact StreamlineMD and we’ll be happy to evaluate the product.
Take Aways
- Always ask WHY no pre-auth is required
- Standardize workflow checklists by procedure type.
- Write reviewer-proof narratives assuming the reviewer is non-IR.
- Document every interaction—especially ‘no auth required’ confirmations.
- Prepare for peer-to-peer reviews using clinical data and guideline citations.
- Leverage pre-auth partners like StreamlineMD for efficiency.
Click here for StreamlineMD’s best practice prior authorization checklist
Bottom Line
- IR prior authorization is a moving target.
- Policies change without notice.
- “No auth” and “urgent” do not guarantee payment.
- Your protection lies in precise documentation, structured workflows, and proactive communication.
- When your notes tell the complete clinical story, you protect both your patients and your revenue.
- Be a good storyteller.
- Be skeptical about AI automation for IR prior auths.
Resources
StreamlineMD firsthand experience
*See a previous blog on prior authorizations here: Help Improve Prior Authorizations
StreamlineMD provides Revenue Cycle Solutions to Radiology & Interventional Specialists. Our Mission is to Improve Healthcare for All Americans. Our Core Values that guide us on our mission are Service Quality, Teamwork, Accountability, Efficiency, Adaptability, Communication, and Integrity. Proud winner of the Great Place To Work award. Learn more about us at streamlineMD.com
