Active Case Study

Reducing Radiology Insurance Denials (PET/CT)

A rules-driven and AI-assisted workflow that improves PET/CT ordering accuracy, payer readiness, and time-to-scan in oncology imaging.

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Executive Summary

Oncology imaging teams face persistent PET/CT insurance denials driven by incorrect study header selection and incomplete medical-necessity documentation. OraDigit designed a hybrid decision-support workflow that standardizes PET/CT orders, aligns them with payer policy, and reduces downstream rework.

The Challenge

Multiple imaging sites reported elevated PET/CT denial rates due to free-text ordering, inconsistent header selection, and documentation that failed to meet payer medical-necessity criteria.

  • Incorrect PET header selection
  • Non-standardized indication language
  • Manual post-order fixes by schedulers and coders
  • Delayed care and revenue leakage

Goals

  • Reduce initial denials and prior-authorization failures
  • Standardize PET/CT study headers
  • Capture payer-aligned medical necessity at order time
  • Shorten time-to-scan and authorization cycles

OraDigit Solution

Deterministic Rules Engine

  • Maps oncology scenarios to PET/CT headers
  • Enforces required clinical and coding inputs
  • Validates indications against payer policy tables
  • Maintains versioned, auditable logic

Guard-railed AI Assistant

  • Drafts payer-ready justification text
  • Explains header choice to ordering providers
  • Flags missing or contradictory inputs
  • Supports CDS without replacing clinical judgment

End-to-End Workflow

  1. Structured web form captures cancer type, intent, stage, therapy status, ICD-10, and prior imaging
  2. Rules engine recommends PET/CT header with alternatives and rationale
  3. AI drafts payer-ready medical-necessity language
  4. Payer readiness checks validate completeness
  5. Export to PDF or EMR for scheduling and authorization

Expected Outcomes

  • 50–70% reduction in PET/CT denials (target)
  • Faster time-to-scan
  • Reduced staff rework
  • Improved provider ordering confidence

Security & Compliance

  • No PHI stored by default
  • BAA-enabled hosted deployment available
  • Audit trail for recommendations
  • Decision support only

Status

In progress: rules table definition, form schema, and AI justification templates. Next phase includes pilot integration and EMR-ready export.

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