A3i HEALTH
Prior Authorizations Simplified
Sample Clinical Scenarios
Real-world examples of proper billing and coding for cardiac PET/CT studies
Standard Rest/Stress PET/CT with Rubidium
Clinical Presentation
68-year-old male with chest pain, hypertension, diabetes, and family history of CAD. Recent stress echo showed equivocal results. Cardiologist orders cardiac PET/CT for definitive risk stratification.
Procedure Performed
Rest and pharmacologic stress myocardial perfusion PET using Rubidium Rb-82 with regadenoson stress agent. CT performed for attenuation correction and anatomical localization.
Proper Coding
- 78431 - Rest and stress myocardial perfusion PET
- A9555 x 2 - Rubidium Rb-82 (2 doses: rest + stress)
- J2785 x 4 - Regadenoson 0.4mg with JZ modifier
Documentation Requirements
- Office notes documenting chest pain characteristics
- Stress echo report showing equivocal findings
- CAD risk factors documented
- Medical necessity statement
Expected Reimbursement (Medicare)
Total: ~$2,927
- 78431: $1,850
- A9555 x2: $532.50 x2 = $1,065
- J2785 x4: $3 X 4 = $12
Absolute Quantification Myocardial Blood Flow
Clinical Presentation
55-year-old female with atypical chest pain and known microvascular dysfunction. Physician requests quantitative myocardial blood flow assessment.
Procedure Performed
Rest and stress PET, including absolute quantification of myocardial blood flow (MBF). CT for attenuation correction.
Proper Coding
- 78431 - Rest and stress myocardial perfusion PET
- 78434 - Absolute quantification of MBF
- A9555 x 2 - Rubidium Rb-82 (2 doses: rest + stress)
- J2785 x 4 - Regadenoson 0.4mg with JZ modifier
Documentation Requirements
- Clinical suspicion of microvascular disease
- Quantitative flow values in report (ml/min/gram)
- Coronary flow reserve (CFR) calculations
- Medical necessity for quantification
Expected Reimbursement (Medicare)
Total: ~$3,352
- 78431: $1,850
- 78434: $425
- A9555 x2: $532.50 x2 = $1,065
- J2785 x4: $3 X 4 = $12
Single Study (Stress Only) Post-Revascularization
Clinical Presentation
72-year-old male 6 months post-CABG with recurrent chest pain. Cardiologist orders stress-only PET to assess graft patency.
Procedure Performed
Pharmacologic stress myocardial perfusion PET only (no rest imaging) using Rubidium Rb-82 with CT for attenuation correction.
Proper Coding
- 78430 - Single study (stress only)
- A9555 x 1 - Rubidium Rb-82 (1 dose for stress)
- J2785 x 4 - Regadenoson with JZ modifier
Documentation Requirements
- Previous CABG documentation
- Recurrent symptoms documented
- Clinical rationale for stress-only protocol
- Medical necessity statement
Expected Reimbursement (Medicare)
Total: ~$2,080
- 78431: $1,536
- A9555 x1: $532
- J2785 x4: $3 X 4 = $12
Medicare Advantage Plan with Prior Authorization
Clinical Presentation
65-year-old female with Medicare Advantage plan, presenting with dyspnea on exertion, diabetes, and abnormal ECG.
Prior Authorization Process
PA submitted 14 days before procedure through plan's PA vendor (eviCore). Approved for CPT 78431, A9555, and J2785.
Proper Coding
- 78431 - Rest and stress PET
- A9555 x 2 - Rubidium doses
- J2785 x 4 - Regadenoson
- PA Reference Number on claim
Documentation Requirements
- All documentation submitted with PA
- PA approval letter on file
- Authorization number referenced on claim
- Services performed within authorized timeframe
Billing Considerations
- Verify in-network status before scheduling
- Confirm PA covers all billed codes
- Submit claim within plan timely filing limit
- Include PA number in Box 23 (authorization number)
Commercial Plan PA Denial & Appeal
Clinical Presentation
62-year-old male with chest pain, commercial insurance. PA requested for cardiac PET/CT. Initially denied due to "insufficient documentation of prior testing."
Appeal Process
- Day 1: Received denial letter
- Day 2: Gathered additional documentation (stress test report, ECG, office notes)
- Day 3: Requested peer-to-peer review
- Day 7: If peer-to-peer review fails, Filed Level 1 appeal with supplemental information
- Day 14-21: PA final disposition received
Key Success Factors
- Prompt response to denial (within 48 hours)
- Comprehensive documentation package
- Peer-to-peer discussion by cardiologist
- Clear articulation of medical necessity
- Reference to clinical guidelines (AHA/ACC)
A3i Support Provided
- Coordinate peer-to-peer scheduling
- Prepare clinical summary for physician
- Compile all supporting documentation
- Track appeal status daily
- Obtain written approval confirmation
Commercial Plan Denial & Appeal
Initial Scenario
62-year-old male with chest pain with commercial insurance received cardiac PET/CT. Claim denied due to "insufficient documentation."
Appeal Process
- Day 1: Received denial letter
- Day 2: Gathered additional documentation (additional office notes, Rubidium invoice)
- Day 3: File Level 1 appeal including requested and supplemental information
- Day 7: Follow up with payer
- Day 14: Final claim payment disposition obtained
Key Success Factors
- Prompt response to denial (within 48 hours)
- Comprehensive claim reconsideration documentation package
- Implement denial management lessons learned
- Ensure that subsequent claims take advantage of lessons learned
A3i Support Provided
- Generated reconsideration package
- Tracked appeal status daily
- Obtained written approval confirmation
Outcome
Claim submitted including PA number. Paid in full within 30 days. Patient received timely cardiac evaluation without delay in care.
Key Takeaways from These Scenarios
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