PET/CT Insurance Denial Reduction
Insurance denials for PET/CT can stall care, delay treatment, and increase costs. OraDigit helps imaging departments and healthcare organizations eliminate unnecessary denials by connecting clinical needs with payer language—so the right scan is approved the first time.
Why It Matters
PET/CT is one of the most powerful imaging modalities in oncology, neurology, and infection/inflammation workups. Yet, across the U.S., denial rates remain high—often due to:
- Incorrect exam headers (e.g., Whole Body used instead of Skull-to-Thigh)
- Poorly phrased clinical indications not aligned with payer policies
- Missing documentation of prior therapy, staging, or necessity
- Tracer or interval restrictions (e.g., FDG timing rules)
Each denial means delays for patients, rework for providers, and lost revenue for healthcare systems. Our solution directly targets these failure points.
Who Benefits
- Hospitals & Imaging Centers: Reduce administrative overhead and accelerate patient scheduling.
- Ordering Providers: One-click order guidance that avoids phone calls and faxes with payers.
- Payers & Utilization Management: Cleaner, policy-compliant orders that lower appeals volume.
- Patients: Faster access to critical scans and treatments.
How OraDigit Reduces Denials
- Real-Time Order Guidance: Maps each clinical scenario to the correct PET/CT header and policy-approved phrasing.
- Documentation Helper: Inserts required language (stage, prior imaging, therapy context) in seconds.
- Policy Guardrails: Flags when an interval, tracer, or indication is outside payer guidelines.
- Analytics Dashboard: Reveals denial patterns, top referrer errors, and educational opportunities.
Examples — Indication to Header
| Clinical Scenario | Recommended PET/CT Header | Notes |
|---|---|---|
| Oncology staging/restaging (lung, breast, GI, GU cancers) | PET/CT Skull-to-Thigh | Standard field-of-view; widely accepted by payers. |
| Melanoma or suspected distal/extremity disease | PET/CT Whole Body | Ensures distal extremities are captured. |
| Neuro-oncology, epilepsy, neurodegenerative evaluation | PET Brain | Dedicated protocol; not billed as whole-body. |
| Infection/inflammation workup (e.g., fever of unknown origin, vasculitis) | PET/CT Skull-to-Thigh | Adjust per clinical question and local policy. |
Checklist for Approval
- Clear diagnosis or suspected condition
- Stage and clinical question (staging, restaging, treatment response)
- Prior therapy or imaging results, when relevant
- Correct exam header (aligned to policy language)
- Tracer information (FDG, etc.)
Helpful Order Text
- “FDG PET/CT Skull-to-Thigh for initial staging of biopsy-proven lung cancer.”
- “FDG PET/CT Whole Body for melanoma with suspected distal extremity involvement.”
- “FDG PET Brain to evaluate refractory temporal lobe epilepsy.”
Wider Healthcare Impact
Denial reduction is not only about faster scans—it improves the entire healthcare ecosystem:
- Health Systems: Less rework, fewer write-offs, higher throughput.
- Insurance Payers: Cleaner, policy-compliant submissions reduce disputes.
- Patients: Faster diagnosis, reduced stress, timelier treatment.
Deployment Options
- Pilot: Focus on your top 2–3 denial categories within 6 weeks.
- Enterprise Rollout: Full integration with Epic, Cerner, or your EHR.
- Continuous Updates: Ongoing payer policy refreshes and analytics.
Last updated: 2025-08-15
Last updated: 2025-08-15