Cardiology’s prior-authorization burden shows up in two distinct places. The first is PCSK9 inhibitors — the most effective LDL-lowering agents available for high-risk patients, gated behind step-therapy documentation that many patients struggle to satisfy. The second is imaging, where a large share of cardiac diagnostic orders passes through radiology benefits managers running their own authorization process, separate from the practice’s standard PA workflow.
The clinical stakes in both cases are high. Patients who need PCSK9 inhibitors are typically at high cardiovascular risk. The imaging that gets delayed or abandoned is diagnostic, not elective.
The numbers in cardiology
A 2017 study in JAMA Cardiology (Navar et al., n=45,029) examined PCSK9 inhibitor prescriptions in commercially insured patients during the drug class’s first year of availability:
- 79.2% of prescriptions were rejected on first submission; only 47.2% ever received PA approval after appeals.
- Of patients who got approved, 34.7% never filled the prescription — out-of-pocket cost was the second barrier after PA.
- Only 30.9% of all prescribed patients ever received therapy.
Layer on the universal burden: 39 prior authorizations per physician per week, roughly 13 hours lost to them, 93% of physicians reporting PA delays care, and 82% reporting PA can lead patients to abandon treatment (AMA 2024). In cardiology, treatment abandonment for a high-risk cardiovascular patient is not a neutral outcome.
Why cardiology is different
- Step therapy that ignores tolerability. PCSK9 inhibitor authorization requires documented failure of maximally tolerated high-dose statin therapy plus ezetimibe. For patients who are genuinely statin-intolerant or can’t tolerate the full statin protocol, assembling payer-acceptable “documented failure” is burdensome — and often requires multiple loops with the payer to establish what evidence they’ll accept.
- Per-payer LDL thresholds. Each payer sets its own LDL threshold for PCSK9 eligibility, sometimes requiring higher baseline LDL than guidelines suggest, and requiring lab values in specific formats.
- Imaging through a separate queue. Cardiac stress testing, coronary CTA, and advanced echocardiographic studies are frequently routed through radiology benefits managers — a parallel authorization system with its own criteria, turnaround times, and documentation requirements. A cardiologist ordering both a medication and diagnostic imaging may be working two entirely separate PA systems simultaneously.
- Recurring re-authorizations. PCSK9 inhibitor approvals often require re-authorization on an annual or more frequent basis, generating recurring documentation overhead for patients who are already on and responding to therapy.
What it costs
The clinical cost is clear: high-risk cardiovascular patients who don’t start PCSK9 inhibitor therapy remain at elevated risk for the LDL-driven events the drug is proven to prevent. The 69% non-initiation rate found in the Navar study — only 30.9% of all prescribed patients ever received the drug — represents the combined impact of PA barriers and cost barriers, each compounding the other. The operational cost is staff time assembling statin-failure histories, LDL records, and cardiovascular risk documentation in each payer’s required format — at roughly $10.81 per manually processed authorization (CAQH 2023) — plus a parallel effort managing imaging PA through a separate system.
How to cut the wait
The PCSK9 authorization packet is structured clinical documentation: statin trials, dosages, tolerability, ezetimibe history, LDL values, cardiovascular risk category. Artificer Health:
- Assembles the step-therapy record — prior agents, maximally tolerated doses, intolerance documentation, and the LDL and risk data each payer requires.
- Matches to the payer’s criteria so the submission satisfies that specific payer’s threshold on the first pass, rather than returning for missing documentation.
- Handles imaging PA routing — assembling the clinical justification for cardiac imaging in the format each RBM requires.
- Tracks re-authorizations so PCSK9 therapy doesn’t lapse on a patient who is responding.
For a high-risk cardiovascular patient, the 69% who never start therapy represent a preventable gap. First-pass approvals in minutes instead of days close that gap.
Sources: Navar AM et al., “Association of Prior Authorization and Out-of-pocket Costs With Patient Access to PCSK9 Inhibitor Therapy,” JAMA Cardiology 2017;2(11):1217–1225; AMA 2024 Prior Authorization Physician Survey (n=1,000); CAQH 2023 Index.