If the treating physician's request for epidural injections is denied by a UR nurse after referral, is this acceptable?

If the treating physician's request for epidural injections is denied by a UR nurse after referral, is this acceptable?

• A. Yes
• B. No
• C. Only the treating physician may deny
• D. The UR nurse may deny if supervised

Answer: (B)

The key idea is who has authority to deny a medical service in a utilization review process. A UR nurse can screen requests for completeness and alignment with policy, but the final denial of a medical procedure—such as an epidural injection—requires clinical judgment from a physician reviewer or the plan’s medical director. Even if supervision is involved, the denial should come from a clinician, not a nurse, because medical necessity determinations hinge on medical expertise. So denying the treating physician’s referral by a UR nurse is not acceptable; the determination should be made by a physician reviewer or medical director according to policy.

The key idea is who has authority to deny a medical service in a utilization review process. A UR nurse can screen requests for completeness and alignment with policy, but the final denial of a medical procedure—such as an epidural injection—requires clinical judgment from a physician reviewer or the plan’s medical director. Even if supervision is involved, the denial should come from a clinician, not a nurse, because medical necessity determinations hinge on medical expertise. So denying the treating physician’s referral by a UR nurse is not acceptable; the determination should be made by a physician reviewer or medical director according to policy.