Your doctor says you need a specific treatment, medication, or procedure. You go through the prior authorization process, and your insurance company says no. Now what?
A prior authorization denial is not the end of the road. It is the beginning of a process you have every right to challenge. Here is what you need to know.
What Is Prior Authorization?
Prior authorization (also called pre-authorization or pre-certification) is a requirement by your insurance company to approve certain services before they are provided. The insurer reviews whether the requested treatment is medically necessary and covered under your plan before agreeing to pay for it.
Common services that require prior authorization include:
- Surgeries and hospital admissions
- Advanced imaging (MRI, CT scans, PET scans)
- Specialty medications (especially biologics and high-cost drugs)
- Mental health and substance abuse treatment
- Durable medical equipment
- Out-of-network referrals
Why Prior Authorizations Get Denied
The most common reasons for denial include:
- "Not medically necessary" — The insurer's reviewer (often a nurse or physician) disagrees with your doctor's assessment.
- Incomplete documentation — The provider did not submit enough medical records or clinical justification.
- Step therapy requirements — The insurer requires you to try a cheaper alternative first.
- Formulary restrictions — For medications, the drug may not be on the insurer's preferred drug list.
- Failure to meet clinical criteria — The insurer uses internal clinical guidelines that your case does not meet.
Step 1: Request the Complete Denial
Call your insurance company and request:
- The specific clinical criteria they used to evaluate the request
- The name and credentials of the reviewer who made the decision
- The exact reason for the denial in writing
- Your plan's appeal procedures and deadlines
Under ERISA and ACA regulations, you have the right to all of this information.
Step 2: Ask Your Doctor for a Peer-to-Peer Review
One of the most effective steps in the prior authorization appeal process is a peer-to-peer review. This is a phone call between your treating physician and the insurance company's medical director.
During this call, your doctor can explain directly why the treatment is necessary, discuss your medical history, and address the insurer's specific concerns. According to the AMA's 2024 Prior Authorization Physician Survey, peer-to-peer reviews frequently result in approval, especially when the initial denial was based on incomplete information.
Ask your doctor's office to request this review. Many prior authorization denials are overturned at this stage.
Step 3: File a Formal Appeal
If the peer-to-peer review does not resolve the issue, file a formal internal appeal. Your appeal should include:
- A letter from your doctor explaining why the treatment is medically necessary and why alternatives are inadequate
- Relevant medical records, test results, and imaging
- Published clinical guidelines from recognized medical organizations supporting the treatment
- Any peer-reviewed studies showing the treatment's effectiveness for your condition
- A citation of your plan's own coverage policy if it supports coverage
Your insurer must respond to a pre-service appeal within 30 days (or 72 hours for urgent cases).
Step 4: Request an Expedited Review for Urgent Cases
If delaying treatment could seriously harm your health, you have the right to an expedited appeal. Under the ACA, insurers must make a decision on expedited appeals within 72 hours. If your doctor certifies that the standard timeframe could jeopardize your health, the insurer must comply with the expedited timeline.
Step 5: File for External Review
If your internal appeal is denied, you can request an independent external review. An external reviewer who is not employed by your insurance company will evaluate your case. Their decision is legally binding on the insurer.
Most states have their own external review processes, and the federal external review process applies to self-insured employer plans. Your denial letter should include instructions for requesting external review.
State-Level Protections
Many states have enacted laws limiting the use of prior authorization or requiring faster decisions. For example:
- Several states require insurers to make prior authorization decisions within specific timeframes
- Some states have "gold card" programs that exempt providers with high approval rates from prior authorization requirements
- Many states require insurers to honor prior authorizations for a set period, even if the patient changes plans
Check your state's Department of Insurance website for specific protections that may apply to you.
How Lysco Can Help
Prior authorization denials often contain dense clinical and legal language that is difficult to interpret. Lysco analyzes your denial, identifies the specific reason and clinical criteria used, and helps you build a strong appeal with the right evidence and citations. Upload your prior authorization denial at lysco.com to get started.
Sources: American Medical Association (2024 Prior Authorization Physician Survey), Affordable Care Act Section 2719, 29 CFR 2590.715-2719, CMS prior authorization final rule (CMS-0057-F, 2024).