CPAP Module 6, Section 3: Reviewing Labs, Imaging, and Clinical Notes for PA Data
MODULE 6: UNDERSTANDING THE PRESCRIPTION & CLINICAL DOCUMENTATION

Section 6.3: Reviewing Labs, Imaging, and Clinical Notes for PA Data

The Core of the Detective Work: Actively Hunting for the Objective Data Points that Win Your Case.

SECTION 6.3

Reviewing Labs, Imaging, and Notes for PA Data

From Data Overload to Targeted Extraction: Becoming a Clinical Evidence Specialist.

6.3.1 The “Why”: The Primacy of Objective Data

In the previous sections, we established the framework for your investigation. You learned to read a prescription for its hidden clues and to navigate the EMR’s structure like a master librarian. Now, we arrive at the heart of the matter: the active hunt for the specific, objective data points that will form the irrefutable foundation of your case. This is the core of the detective work.

It is essential to understand the payer’s mindset. A clinical reviewer at an insurance company is tasked with making an approval or denial decision based on a rigid set of pre-defined criteria outlined in their clinical policy. While a provider’s eloquent, narrative description of a patient’s suffering in a progress note provides important context, it is ultimately subjective. It is open to interpretation. An objective, quantifiable data point, however, is not. An HbA1c of 9.4%, a Left Ventricular Ejection Fraction of 35%, or a pathology report that confirms “PD-L1 expression of 75%” are hard, verifiable facts. They are binary—they either meet the policy criterion, or they do not.

In the currency of prior authorization, objective data is the gold standard. It is the evidence that is most credible, most defensible, and most likely to result in a swift approval. Your role as a PA pharmacist must therefore evolve. You are no longer just a clinician who evaluates data for patient safety; you are now also an evidence specialist who hunts for specific data points to satisfy bureaucratic requirements. This requires a new level of focus and a new set of targeted skills. You must learn to skim through pages of narrative to find the one sentence that matters. You must learn to parse complex pathology and imaging reports to extract the single, critical finding. This section is your masterclass in that hunt. We will teach you how to become a data miner, sifting through the digital mountain of the EMR to find the nuggets of objective gold that will win your case.

Pharmacist Analogy: The Forensic Accountant of Clinical Data

Imagine a high-stakes corporate fraud case. A regular accountant can tell you the company’s profits and losses. A forensic accountant, however, is brought in to investigate a specific allegation according to a strict set of legal statutes (the “payer policy”). They are not there to read the CEO’s annual letter to shareholders (the “subjective narrative”). They are there to find the hard numbers.

The lead investigator gives them their mission: “The law requires us to prove the company made a specific fraudulent wire transfer of over $1 million to an offshore account in the third quarter.” This is the PA criterion.

The forensic accountant doesn’t start by reading employee emails. They go straight to the evidence locker. They know exactly what they need:

  • They bypass the narrative reports and go directly to the “Transaction Logs” (the Lab Results tab).
  • They ignore thousands of legitimate transactions and use their search tools to filter for international transfers over $1M that occurred between July 1 and Sept 30.
  • They pinpoint a single transaction: a wire transfer of $1.2M on August 15th to a specific account number (the definitive lab value).
  • They pull the official bank confirmation document (the source report, like a pathology report) that validates this single transaction.

They have successfully ignored 99.9% of the available information to find the 0.1% that is legally dispositive. They didn’t just review the data; they conducted a targeted hunt for a specific, objective, and verifiable fact. This is your new role. You are a forensic accountant of clinical data, and this section is your training manual.

6.3.2 Masterclass on Mining Laboratory Data

Laboratory results are the bedrock of objective evidence. They are quantitative, date-stamped, and generated by a calibrated instrument, making them highly credible to payers. The Labs tab in the EMR is your “bank statement,” and learning to read and interpret it through the lens of a payer policy is a fundamental PA skill. Your job is not just to see the value, but to understand its significance and present it as definitive proof.

Navigating the Lab Tab: Tools of the Trade

Before diving into specific examples, you must master the tools of the Lab section itself. Do not passively scroll. Use the EMR’s built-in functions to work efficiently:

  • The Search Bar: Never scroll through a giant list of labs. Always use the search bar. Know what you’re looking for (e.g., “A1c,” “Creatinine,” “LDL”) and search for it directly.
  • Date Filters: This is your most important tool. Payer policies are obsessed with timeliness. A criterion of “LDL > 70 mg/dL” is always followed by “…within the last 90 days.” Use the date filter to narrow your search to the relevant time period *before* you start looking at values.
  • The Graphing/Trending Function: This is a powerful visual tool. For re-authorizations, showing a graph of a patient’s inflammatory markers (CRP/ESR) steadily decreasing since starting a biologic is a slam-dunk argument for continuation. Conversely, for an initial authorization, showing that a patient’s A1c has been trending upwards despite being on metformin and glipizide is powerful proof that they require a more advanced therapy.

Lab Data Deep Dives by Therapeutic Area

A forensic examination of the key data points required for common, high-cost drug classes.

Deep Dive 1: Endocrinology (Diabetes – GLP-1 RAs & SGLT2is)

This is one of the most common areas for prior authorization. Payers want to ensure these expensive agents are reserved for patients who truly need them and have failed cheaper alternatives. Your lab-hunting skills are paramount.

Primary Targets: Hemoglobin A1c (HbA1c), Serum Creatinine (SCr) / eGFR, Urine Albumin-to-Creatinine Ratio (UACR).

The Stale Date Gotcha: A Cardinal Sin in PA

It cannot be overstated: the date of the lab result is as important as the value itself. A common policy requirement is “HbA1c > 8.0% within the last 90 days.” If you find a qualifying A1c of 8.5% but it’s from 8 months ago, it is worthless for your submission. This is a top reason for denial. Your first step should always be to filter by date. If no recent labs exist, your job shifts to communicating this gap to the provider’s office. They may need to order a new lab before the PA can even be submitted.

Masterclass Table: Mapping Diabetes Labs to Policy Criteria
Target Lab Why It’s a PA Target How to Find & Interpret It for a PA Submission
Hemoglobin A1c (HbA1c) This is the primary measure of glycemic control and is used to establish diagnosis, disease severity, and treatment failure. Policies will have specific thresholds (e.g., “> 8.0%” for initial therapy, or “failure to decrease by 1%” for re-auth).
  1. Search “A1c” or “Hemoglobin A1c” in the lab tab.
  2. Filter for the last 3-6 months.
  3. Identify the most recent value. Does it meet the policy threshold (e.g., > 8.0%)?
  4. Pro Tip: Trend the last 3-4 values. If the patient was on metformin and their A1c went from 7.9% -> 8.1% -> 8.5%, you have objective proof of treatment failure. Mention this trend in your submission.
eGFR (estimated Glomerular Filtration Rate) This is used for two main reasons: 1) As a contraindication to metformin (if eGFR is too low, often <30), which is a valid reason to bypass step-therapy. 2) As a specific indication for certain SGLT2 inhibitors (e.g., Jardiance, Farxiga) which have proven renal benefits.
  1. Search “Creatinine” or “eGFR” (eGFR is usually calculated automatically with every Serum Creatinine in the BMP/CMP).
  2. Find the most recent value.
  3. If proving metformin failure: Is the eGFR < 30 mL/min/1.73m²? If so, you have your contraindication.
  4. If proving a renal indication: Does the eGFR fall within the specific range required by the policy (e.g., “between 25 and 75”)?
UACR (Urine Albumin-to-Creatinine Ratio) This is the key lab for detecting albuminuria, a sign of diabetic kidney disease. It is a required piece of evidence for using SGLT2is or finerenone for their renal-protective benefits. Policies will have a specific threshold (e.g., “UACR > 30 mg/g”).
  1. This is a urine test, not a blood test. Search for “Albumin Urine” or “UACR.”
  2. Find the most recent value. Does it meet the policy’s threshold for albuminuria?
  3. Note: This is a less commonly ordered test than an A1c, so it’s often a “missing piece of evidence” you’ll need to request from the provider.
Deep Dive 2: Cardiology (Statins, PCSK9 Inhibitors, & Heart Failure)

Cardiology PAs are all about hitting specific, evidence-based numerical targets. Your job is to find the lab values and echocardiogram results that prove the patient’s risk is high enough to warrant expensive therapy.

Primary Targets: Lipid Panel (specifically LDL-C), Left Ventricular Ejection Fraction (LVEF), Brain Natriuretic Peptide (BNP).

Trending is Your Friend: The Power of Visual Evidence

For a PCSK9 inhibitor request, one of the most powerful arguments is to demonstrate failure of statin therapy over time. Don’t just submit the single most recent LDL value. Use the EMR’s graphing function to create a trendline. A graph showing the patient’s LDL staying stubbornly above 100 mg/dL over 12 months despite being on atorvastatin 80mg is a visually compelling story that is much harder for a reviewer to ignore than a single number. You can often attach a screenshot of this graph to your submission.

6.3.3 Decoding Imaging Reports for Definitive Evidence

If lab results are the bank statements, imaging reports are the official blueprints, photographs, and architectural surveys of the case. They provide objective, expert-validated evidence of structural diagnoses, disease severity, and progression. However, these reports are dense with technical jargon. Your skill lies in knowing how to ignore 99% of the report to find the 1% that matters: the definitive conclusion.

The Golden Rule of Imaging Review: You Are NOT a Radiologist

This is the most important principle in this section. It is not your job to look at the pixels of an MRI scan or to interpret the shadows on a CT. Your job is to find the official, signed report from the expert (the radiologist, cardiologist, etc.) and extract their professional conclusion. Always scroll immediately to the “IMPRESSION” or “CONCLUSION” section at the bottom of the report. This section is the radiologist’s official summary and diagnosis. It is the only part of the report that a payer considers to be authoritative evidence.

️ Imaging Report Deep Dives by Specialty

Extracting the key findings from expert interpretations.

Deep Dive 1: Cardiology (Echocardiograms – The Heart Failure Keystone)

For many advanced heart failure medications, particularly sacubitril/valsartan (Entresto), the entire case rests on one number from the echocardiogram report.

Primary Target: Left Ventricular Ejection Fraction (LVEF).

The Hunt:

  1. Navigate to the Imaging or Cardiology tab and locate the most recent “Echocardiogram Transthoracic” report.
  2. Ignore the pages of measurements and doppler velocities. Scroll directly to the “IMPRESSION” or “SUMMARY AND CONCLUSION” section.
  3. Look for a sentence that explicitly states the LVEF. It will look like this:
    “1. The left ventricular ejection fraction is severely reduced, estimated at 30-35%.”
  4. This number is your gold. A typical Entresto policy requires an LVEF of ≤ 40%. You have now found the objective proof. Your submission should quote this sentence and the date of the report directly.

Deep Dive 2: Oncology (CT / PET / MRI Scans – Staging and Progression)

In oncology, imaging is used to stage the cancer and, crucially, to determine if the cancer is responding or progressing on a given therapy. Proving “progressive disease” is the key to getting a second- or third-line therapy approved.

Primary Target Keywords: “Progressive disease,” “progression,” “new metastatic lesions,” “increase in size.”

The Hunt:

  1. You need at least two scans to show progression: a baseline scan (from before or early in the current treatment) and a recent scan.
  2. Open the most recent CT or PET scan report and go to the “IMPRESSION” section.
  3. The radiologist will often explicitly compare to the prior scan. You are looking for a statement like this:
    “IMPRESSION: Compared to the prior study of 12-AUG-2025, there is an increase in the size of the known liver metastases, consistent with progressive disease. Additionally, there are new osseous metastatic lesions in the lumbar spine.”
  4. This single paragraph is irrefutable evidence that the current therapy has failed. It contains all the keywords a payer looks for: “increase in size,” “progressive disease,” and “new lesions.” You will quote this in your submission to justify the switch to the next line of therapy.

6.3.4 The Art of Unstructured Data Mining: Pathology and Specialty Reports

Welcome to the most advanced level of the investigation. While labs and imaging reports are relatively structured, pathology reports, operative reports, and genetic testing results are often dense, text-heavy documents. They contain the most specific and often the most critical data for modern specialty drugs, but you need to know how to dissect them.

Deep Dive 1: The Pathology Report – The Ultimate Source of Truth

For any cancer diagnosis, the pathology report is the foundational document. It is not optional. It is the definitive proof of the cancer’s existence, type, and, crucially, its molecular and genetic characteristics. For targeted oncology therapies, the entire PA case is built upon the findings in this report.

Primary Targets: The “Final Diagnosis” section, Immunohistochemistry (IHC) results (e.g., ER, PR, HER2, PD-L1), and Molecular/Genetic testing results (e.g., EGFR, BRAF).

Anatomy of a Pathology Report: A PA-Focused Guide
Report Section What It Contains Your PA Focus
Specimen Describes the source of the tissue (e.g., “Right breast mass core biopsy”). Quickly verify it’s the correct tissue source for the diagnosis in question.
Gross / Microscopic Description Technical description of what the tissue looks like to the naked eye and under the microscope. IGNORE. This is highly technical and not relevant for your purposes.
Final Diagnosis The definitive, final diagnosis. This is the ultimate conclusion. CRITICAL. This is where you confirm the exact cancer type (e.g., “Invasive Ductal Carcinoma”). This must match the ICD-10 code.
Immunohistochemistry (IHC) / Ancillary Studies Results of special stains and tests performed on the tumor tissue to determine its characteristics. THE GOLDMINE. This is where you find the biomarker data. You must hunt for the specific results:
  • Breast Cancer: Estrogen Receptor (ER), Progesterone Receptor (PR), HER2 status.
  • Lung Cancer: PD-L1 expression level (e.g., Tumor Proportion Score or TPS).

Example Hunt: For a Keytruda (pembrolizumab) PA for non-small cell lung cancer, the policy requires “PD-L1 expression ≥ 50%.” You will find the lung biopsy pathology report, go to the “Ancillary Studies” section, and look for the line that says:

“PD-L1 (22C3 pharmDx) stain is performed and shows a Tumor Proportion Score (TPS) of 80%.”
You have just found the single most important piece of data for the entire case.