Prior authorization · Pre-submission
Pre-submission risk
Denial risk by case before submission, from policy gaps, payer history and site
PreviewNot in this phase. Denial-risk scoring before a packet goes to the payer. Static sample data; rows open a read-only detail.
High risk
4
score ≥ 55
Medium risk
5
score 30–54
Low risk
3
score < 30
Average score
43
12 cases not yet submitted
Cases by denial risk
12 rows
| Patient | Payer | Site | Score | Risk | Top driver | Recommended action |
|---|---|---|---|---|---|---|
| Priya Raman | Aetna · Open Access PPO | H&N re-irradiation | 72 | High | Composite cord/brainstem dose not in chart | Dosimetry to build composite plan before submission |
| Ray Okonkwo | UHC · Navigate HMO | Skull base | 69 | High | Initial review pended for medical director | Prepare peer-to-peer talking points (brainstem constraint) |
| Dell Whitfield | VA CCN · Community Care | Prostate | 64 | High | VA referral / SEOC not yet approved | Call VA community care office; request SEOC status |
| Graham Holt | Cigna · Open Access Plus | Lung (stage III) | 58 | High | Heart V30 advantage below payer threshold | Ask dosimetry to re-optimize or add esophagus/lung rationale |
| Nadia Haddad | Aetna · Open Access PPO | Sinonasal | 45 | Medium | Tumor board review pending (Oct 2) | Hold submission until tumor board note is signed |
| Marcus Delgado | UHC · Choice Plus (American Airlines) | Oropharynx | 41 | Medium | Unsigned attestation; dental clearance missing | Dr. Lee to sign; request dental clearance letter |
| Thomas Brennan | Humana · Gold Plus HMO | Prostate | 38 | Medium | IMRT comparison plan not generated | Dosimetry to generate VMAT comparison with rectal/bladder DVH |
| Kenji Mori | UHC · Navigate HMO | Nasopharynx | 36 | Medium | PET/CT at 84 days, near 90-day limit | Submit before Oct 6 or re-image |
| Victor Lindqvist | UHC · Choice Plus (Dell Technologies) | Liver (HCC) | 33 | Medium | Site not listed in §II.A covered indications | Attach liver tumor board and normal-liver dose rationale |
| Lorna Pike | Cigna · Open Access Plus | Esophagus | 22 | Low | None — packet complete | Submit via Cigna portal |
| Ana Sobrino | BCBS TX · Blue Choice PPO (Walmart) | Left breast | 18 | Low | None — predetermination sent | Await decision (due Oct 8) |
| Rosa Delacroix | Aetna · Open Access PPO | Right breast | 15 | Low | None | Build packet |