Denying the Denials: AI in Pre-Authorizations

​

The insurance side of AI

 

Centers for Medicare and Medicaid Services (CMS) does not require insurers to disclose how they make authorization decisions or how predictive technologies factor into the process. A 2025 survey found that most insurers are now using AI, with 68% using it for prior authorization reviews. The battle lines are drawn when decisions to deny care are made without human oversight. In this same survey, only 12% of insurers said they used or were considering using, AI specifically to deny prior authorizations. 

 

The provider pushback

 

Prior authorization is costly for providers, who spent an estimated $13 billion in 2023 on administration burden. New tools help healthcare providers complete tasks such as appealing denials. One example is Claimable, which collects patient and coverage information to generate and send appeal letters to insurers. 

 

Battle of the bots

 

For now, this landscape is shaping up like an arms race where insurance bots deny claims, only to be met with automatic appeals from the provider. Courts are beginning to weigh in as insurance giants face lawsuits from patients alleging AI-driven denials occurred without required human oversight.

​​

Peripheral Nerve Blocks (PNBs) and Post-Op Pain:
Help or Harm

by Vince Vacketta, DPM

 

PNBs have become a popular tool for managing pain after orthopedic surgery, but a new look at nearly 23,000 patients at Massachusetts General Hospital suggests the story is more nuanced.

 

This single-center retrospective study compared patients who received single-injection PNBs with those who did not. In the recovery room, the benefits were clear: patients with PNBs reported lower peak pain scores and required fewer opioids. But once the block wore off, a different picture emerged: many experienced “rebound pain,” with higher maximum pain scores and about 23% greater total opioid use during the hospital stay than those without a block.

 

Key findings:

 

• Immediate recovery (PACU): Lower maximum pain scores and reduced opioid use with PNBs

• Later in the hospital stay: Rebound pain with higher maximum pain scores and 22.7% higher total opioid consumption

• After discharge: More opioid prescriptions at 30 days; no differences at 90 or 180 days

• At one year: Slightly lower rates of new chronic pain diagnoses

 

Overall, the study suggests that while PNBs offer excellent early relief, they may set patients up for a challenging rebound phase if not supported by a broader pain-management plan, 

 

The takeaway: PNBs ease immediate pain but can paradoxically heighten later pain and opioid use if not paired with a comprehensive pain-management plan.

 

 

Ligament Augmentation in Lateral Ankle

 

Ligament augmentation in lateral ankle reconstructions got a big boost with the publication of a Level 1 paper showing superior two- and five-year outcomes when using a ligament augment. Since then, the market has expanded with offerings from Stryker (Artelon), Arthrex (Internal Brace), Conmed (BioRez), and Medline (ForceWeb).

 

Augment use in ortho foot and ankle

 

In an online survey of American Orthopaedic Foot & Ankle Society (AOFAS), 85.7% reported using ligament augments. North American surgeons were significantly more likely to use them than those outside of North America (89% vs. 72%). The most augmented ligament was the anterior talofibular ligament ATFL (98.1%), followed by the syndesmosis (59.8%) and the deltoid ligament (58.4%). 

 

Faster return to sport

 

The most commonly cited reason for ligament augment use was to enable faster return to sport (136 respondents, 65.1%). This contention is supported by Kulwin et al., whose multicenter, prospective, randomized trial found that augmentation can facilitate an earlier return to athletic activity. 

​