A prior authorization denial means your insurer won't approve a treatment or service before you receive it. This is one of the most frustrating denial types because it delays your care. But you have specific rights and strategies to fight it.
Understanding Prior Authorization Denials
Why PAs Are Denied
- Treatment not meeting insurer's clinical criteria
- Insufficient documentation submitted by provider
- Alternative treatment available (step therapy required)
- Provider submitted wrong codes
- PA request expired before treatment was done
Immediate Steps
- Get the specific denial reason in writing
- Ask your doctor's office to check if it was a documentation issue (often fixable quickly)
- Request peer-to-peer review — your doctor calls the insurer's medical director
- File an expedited appeal if the treatment is urgent
Expedited Appeal for Urgent PA Denials
If waiting for standard appeal timelines would seriously jeopardize your health:
- Request an expedited appeal
- Insurer must decide within 72 hours (24 hours in some states)
- Your doctor can request this on your behalf
Step Therapy Exceptions
If the PA was denied because you haven't tried a "preferred" treatment first:
- Request a step therapy exception if:
- You've already tried and failed the preferred treatment
- The preferred treatment is contraindicated
- The preferred treatment would cause harm
- You had a previous successful course of the requested treatment
- Many states have step therapy reform laws supporting exceptions
PA Reform Efforts
- CMS Interoperability Rule (2024): Requires faster electronic PA for Medicare Advantage
- Gold carding: Some states (TX) exempt providers with high approval rates from PA