Reducing Denials: Help in Mitigation

*Excerpted from the 2026 Annual Meeting Presentation

Denials have increased over the last few years, something that all practices have likely experienced. It can be challenging to have a treatment or procedure that works, but denied coverage means the treatment cannot be administered. Sometimes, you have to adapt how you practice to what the billers say.

During this year’s Annual Meeting in Tucson (9/2026), Rebecca Kamil, MD; Arvin Rao, MD; Keith Sale, MD; James Ludwick, MD; and Kevin Wilson, MD spoke about denials and strategies for avoiding and mitigating them in their panel discussion.   Here are some key take aways:

Common and Costly Denial Changes

Posterior Nerve Ablation

• Posterior Nerve Ablation is often denied as experimental, though the AAOA has submitted a formal position statement supporting medical necessity in hopes of gaining payer coverage.
• Steps to Improve Reimbursement:
  • Find out if the treatment is covered beforehand, so your practice won’t have to double back later if the patient’s insurance denies it.
  • Provide out-of-pocket costs up front for the patient.
    • For example, collect a deposit equal to twice of the cost of the wand for Posterior Nerve Ablation.
    • Ensure that the patient is requesting the procedure in writing and paying for it out-of-pocket.
  • Make sure documentation and submission to insurance is up-to-date and includes all necessary information (imaging of failed medical management, notes, guidelines).
• Medicare does not have an National Coverage Determination (NCD) or Local Coverage Determinations (LCD) on Posterior Nerve Ablation.

Biologics

• Assume your first submission will be denied and build a process around the appeal.
• Look at the most restrictive policy and find the indications within that policy.
  • Speak the language of the insurance policies.
  • Writing in their words will help you avoid denials.
• Connect with your billing team, if you have one, on new procedures/treatments.

Imaging

• CT and MRI denials typically cite lack of medical necessity.
• Avoid generic order language and be precise within the scope of the insurance policy.
• For CT Sinus, document prior antibiotic courses, steroids, topical sprays, and allergy evaluations.

Referrals for Allergy Testing

• Allergy testing denials typically cite lack of medical necessity.
• Stay within the standard of care, i.e. standard number of allergens.

Explore Technology and Tools to Streamline Denials

• Fighting Fire with Fire: Insurance is using AI to deny claims. The following uses of AI, for practices, are some of the easiest ways to implement AI. If directed properly, AI matches wordage to policy, gets the right language, and gets the right references.
  • However, be careful in how your practice uses AI. Uploading protected health information into publicly accessible tools can come back to your practice if the AI tool suffers a data leak. That patient information is HIPAA protected.
  • To avoid denials, it is imperative to write letters along with submissions. Submitting records without a letter can increase the likelihood of a denial.

AI-Assisted Appeal Letters

• AI tools can draft medically precise, guideline-referenced, appeal letters.
• These tools can reduce staff burden and improve consistency/quality of language within submissions.

OpenEvidence

• OpenEvidence is a clinical evidence tool that rapidly surfaces peer-reviewed literature and guidelines.
• Tools similar to this can find the strongest supporting evidence for any denial appeal.

For more on this Mitigating Denials panel and to access the full program content, the AAOA’s 2026 Annual Meeting is available virtually until October 15, 2026. Please follow this link for information on how to register and access virtual content.