Prior authorization denials are among the most frustrating — your doctor ordered a treatment, but your insurer says no before you can even receive it. Understanding how to navigate and appeal prior authorization requirements can mean the difference between getting timely care and dangerous delays.
Understanding Prior Authorization
Prior authorization (PA) is a requirement that your doctor get approval from your insurer before providing certain services. Common services requiring PA:
- Specialty medications (especially biologics)
- Advanced imaging (MRI, CT, PET scans)
- Surgical procedures
- Inpatient hospital stays
- Certain specialist referrals
- Durable medical equipment
Why Prior Authorization Gets Denied
- Insufficient documentation — the request didn't include enough clinical information
- Doesn't meet clinical criteria — the insurer's guidelines aren't satisfied
- Alternative treatment available — the insurer wants a cheaper option tried first
- Wrong provider submission — the request was submitted incorrectly
How to Appeal
Immediate Steps
- Get the specific denial reason and clinical criteria used
- Ask your doctor about a peer-to-peer review
- Determine if your condition qualifies for an expedited (72-hour) appeal
Building Your Appeal
- Include all clinical documentation supporting the request
- Address the specific denial criteria point-by-point
- Provide evidence of failed alternatives
- Cite clinical guidelines supporting the treatment
- Include a physician letter of medical necessity
Retroactive Authorization
If you received the treatment without PA (emergency or oversight):
- File a retroactive authorization request
- Provide documentation showing the care was medically necessary
- Cite the Prudent Layperson Standard for emergency services
CMS Prior Authorization Final Rule (2025)
New federal rules effective 2025-2026 require:
- Electronic PA processing
- PA decisions within 72 hours for urgent requests
- PA decisions within 7 days for standard requests
- Transparency about PA approval rates
- Specific reasons for PA denials