Reducing Radiology Insurance Denials (PET/CT)

A practical, compliant workflow to help oncology providers and radiology teams pick the correct study headers and document medical necessity.

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Summary

Multiple sites reported unusually high denial rates for PET/CT orders driven by two issues: (1) incorrect study header selection (e.g., PET Whole Body vs. PET Skull‑to‑Thigh), and (2) indication text that did not align with payer medical‑necessity criteria. This caused repeat scheduling, staff rework, delayed care, and revenue leakage.

Goals

  • Cut initial claim denials and prior‑auth rejections.
  • Standardize ordering with compliant study headers.
  • Capture clinically accurate indications mapped to payer rules.
  • Shorten time‑to‑scan; reduce back‑and‑forth with payers.

What exists today (baseline)

  • Current ordering portals allow free‑text reasons and broad header choices.
  • Site protocols favor PET Skull‑to‑Thigh for most adult oncology; Whole Body is needed in select scenarios (e.g., suspected distal disease).
  • Schedulers/coders often fix orders post‑hoc; documentation quality varies by referrer.

OraDigit Solution (Hybrid: Rules + LLM)

Deterministic Rules Engine

  • Maps clinical scenarios to PET/CT headers (e.g., staging/restaging vs. therapy response).
  • Enforces required fields: diagnosis, stage, therapy status, ICD‑10, prior imaging.
  • Validates indication against a versioned payer‑policy table.

Guardrailed LLM Assistant

  • Drafts payer‑ready justification using structured inputs (explainable templates).
  • Explains header choice to the ordering provider in plain language.
  • Flags contradictions or missing fields before submission.

Workflow

  1. Web Form on oradigit.com captures structured inputs (cancer type, intent, stage, therapy status, ICD‑10, prior imaging, symptoms).
  2. Header Recommendation from rules; alternatives shown with rationale.
  3. Justification Draft (LLM) + suggested diagnosis codes.
  4. Payer Readiness Check (required fields, policy alignment, prior‑auth hints).
  5. Export to PDF/EMR note for scheduling and authorization.

Inputs & Data

  • Ordering details: known/suspected malignancy, stage, intended use (staging, restaging, surveillance), therapy response.
  • Facility protocols: preferred headers (Skull‑to‑Thigh, Whole Body), tracer, dose ranges.
  • Payer rules (summarized): medical necessity language, documentation requirements.

Security, Privacy & Compliance

  • No PHI stored by default; hosted options with BAA available.
  • Versioned policy table; audit trail of recommendations.
  • Decision support only—does not replace clinical judgment.

KPIs & Expected Outcomes

  • Denials ↓ 50–70% within 90 days at pilot sites (target).
  • Time‑to‑scan ↓ via complete orders on the first pass.
  • Staff rework ↓ (fewer resubmissions and payer calls).
  • Provider experience ↑ (explainable, consistent ordering).

Status

In progress: rules table definition, form schema, and draft LLM templates. Next: pilot integration and PDF/EMR export.

Start a pilot
See PET/CT example in OraDigit Labs