7 ways to cut prior authorization denials in an orthopedic practice

Orthopedic practices order a lot of what payers scrutinize most: advanced imaging, injections, and joint and spine surgery. The good news is that denials cluster. Fix the few patterns behind most of them and your first-pass approval rate moves.

1. Find your top five denied services

Pull the last 90 days of denials and group them by service and payer. Most practices find a short list, often lumbar MRI, epidural injections, and arthroplasty, behind most of their denials.

2. Get the actual policies

For each of those services and your main payers, download the current medical policy or coverage document. Don't rely on memory; criteria change.

3. Turn criteria into note templates

Build smart phrases that prompt for exactly what the policy asks: therapy type and dates, response, exam findings, red flags, and how the result will change management.

4. Document conservative care with dates

"Failed conservative treatment" is the most common weak phrase in a denied note. Write the therapy, the dates, the duration, and the response.

5. Record objective findings, not just symptoms

Strength by muscle group, reflexes, provocative tests with results, and range of motion with numbers. Reviewers look for these.

6. Use specific, current codes

Deleted or non-specific ICD-10 codes trigger avoidable denials. For example, M54.5 was deleted in October 2021. Audit your favorites list once a year.

7. Read every denial reason, then track it

Since January 2026, Medicare Advantage, Medicaid, and CHIP plans must give a specific reason when they deny a prior authorization. Log those reasons. Repeated reasons are your next template fix.

Measure one number: the share of requests approved on first submission. Every change above should move it.

General information, not billing or medical advice. Confirm requirements against each payer's current policy.