Reports from Cooper University Health Care Advance Knowledge in Managed Care (Magnetic Resonance Imaging Prior Authorizations for Orthopaedic Care Are Negatively Affected By Medicaid Insurance Status): Managed Care

Insurance Daily News

2025 FEB 28 (NewsRx) -- By a News Reporter-Staff News Editor at Insurance Daily News -- Investigators publish new report on Managed Care. According to news reporting originating in Camden, New Jersey, by NewsRx journalists, research stated, “Magnetic resonance imaging (MRI) has revolutionized musculoskeletal care. However, its high costs and high utilization has prompted many insurance payors to require a prior authorization.”

The news reporters obtained a quote from the research from Cooper University Health Care, “This process remains burdensome and results in delays to patient care. The purpose of this study was to examine the relationship between several variables and the denial rate of outpatient MRI prior authorization requests from a single institution’s department of orthopaedics. MRI prior authorization insurance data was retrospectively collected from January 2019 to December 2022. Patient demographics, imaging characteristics, and insurance details were extracted and stratified into generalized categories. Analysis of variance, multivariate logistic regression models, and odds ratios (ORs) were used to predict the likelihood of request denial with alpha = 0.05. Of the 17,913 total MRI prior authorization requests identified, 885 (4.94%) were denied. Race and socioeconomic status were not markedly different between the authorized and denied cohorts; however, primary insurance payor, chief symptom, and anatomic location to be imaged were found to have notable differences between authorized and denied cohorts (P < 0.0001). MRIs of the spine were less likely to be authorized compared with the shoulder (OR 0.51), upper extremity (OR 0.43), knee (OR 0.38), lower extremity (OR 0.34), and foot and ankle (OR 0.75) with P< 0.02 for each. Horizon NJ Health and Horizon Blue Cross Blue Shield, both Medicaid payors, were also less likely to authorize requests compared with other payors (Aetna, OR 0.37 and United Healthcare, OR 0.36) (P < 0.01 for both). The low denial rate of initial prior authorization requests over 4 years at our institution underscores the questionable utility of the prior authorization process. Our results are consistent with the current literature that has reported higher rates of denials for MRI prior authorization requests of the spine. Although we were not able to quantify the effect of these denials on patient care, the overall time required to process these requests undoubtedly causes delays in patient care. despite no notable difference seen in socioeconomic status, Horizon NJ Health, a major provider of only Medicaid insurance plans at our institution, was associated with a higher likelihood of denial.”

According to the news reporters, the research concluded: “This suggests that MRI prior authorization requests submitted for Medicaid patients are more likely to be denied and cause an inequitable delay in care due to this process.”

This research has been peer-reviewed.

For more information on this research see: Magnetic Resonance Imaging Prior Authorizations for Orthopaedic Care Are Negatively Affected By Medicaid Insurance Status. Journal of the American Academy of Orthopaedic Surgeons, 2025;33(4). Journal of the American Academy of Orthopaedic Surgeons can be contacted at: Lippincott Williams & Wilkins, Two Commerce Sq, 2001 Market St, Philadelphia, PA 19103, USA.

Our news correspondents report that additional information may be obtained by contacting Samantha Harrer, Cooper University Health Care, Dept. of Orthopedic Surgery, Camden, NJ 08103, United States. Additional authors for this research include Kathryn Hedden, Pietro M. Gentile, David B. Gealt, Matthew L. Brown, Sadegh Mikaeili and Nazila Bazrafshan.

The direct object identifier (DOI) for that additional information is: https://doi.org/10.5435/jaaos-d-24-00442. This DOI is a link to an online electronic document that is either free or for purchase, and can be your direct source for a journal article and its citation.