This skill tells Ohtari how to handle prior authorization for spine procedures. The ⊞ Spine prior auth orchestration workflow reads from this at runtime — the workflow does not embed this logic, it consults this skill.

Payer-specific evidence requirements

UnitedHealthcare — requires documented conservative care, including PT attendance (not just referral), imaging within the prior 6 months, and a clinical narrative explaining functional impairment. @ Karen Mitchell reviews UHC packets before submission.

Aetna — accepts standard CMS documentation. The PA workflow assembles imaging, op report draft, and conservative care timeline. Auto-submitted via Availity unless flagged.

BCBS — varies by state plan; pull payer-specific template from ▤ BCBS state plan reference.

Cigna — frequent peer-to-peer requests for fusion procedures. Schedule the call automatically and brief the surgeon 24 hours in advance using ⊞ Peer-to-peer prep brief.

Conservative care timeline

1. ≥ 6 weeks of physical therapy with documented attendance and functional measures (ODI, VAS).
2. NSAID or other conservative pharmacologic management for ≥ 4 weeks.
3. Activity modification documented in clinical notes by the referring or treating provider.

When to escalate to a partner

If a payer denial cites criteria not covered above, escalate to @ Dr. Voss or @ Dr. Halloway via the surgeon mobile push. The workflow pauses until the surgeon responds.