What Is Prior Authorization — and Why Does It Matter?
Prior authorization (also called prior auth, pre-authorization, or pre-certification) is a requirement that your doctor get approval from your insurance company before providing certain treatments, medications, or procedures. It is one of the most contentious tools in managed care — and one of the leading sources of coverage disputes.
When prior authorization is denied, patients are often left in an agonizing position: their doctor has recommended a treatment they need, but the insurance company says no. Understanding why this happens — and how to push back — is essential.
Why Prior Authorization Requests Get Denied
Failure to Meet Step Therapy Requirements
Also called "fail first" requirements, step therapy means your insurer requires you to try less expensive treatments before approving the one your doctor originally prescribed. If the documentation doesn't show you've tried and failed the required "step" treatments, the request is denied.
Insufficient Clinical Documentation
Insurers use standardized clinical criteria (often from organizations like InterQual or MCG) to evaluate requests. If your doctor's submission doesn't include the specific data points the insurer is looking for — diagnosis codes, lab results, prior treatment history — denial is almost automatic.
"Experimental or Investigational" Designations
If an insurer classifies a treatment as experimental, they can deny prior authorization. This designation is often applied too broadly, particularly for newer therapies that have strong clinical evidence but haven't yet appeared in the insurer's clinical guidelines.
Out-of-Network Provider
Prior authorization requests for out-of-network providers are frequently denied unless the patient can demonstrate there is no in-network provider capable of delivering the necessary care.
How to Appeal a Prior Authorization Denial: Your Game Plan
Step 1: Get the Denial in Writing
Your insurer must provide the specific clinical criteria used to deny the request. Obtain this immediately — it tells you exactly what information gap you need to fill.
Step 2: Have Your Doctor Write a Detailed Letter of Medical Necessity
This is the single most important step. The letter should:
- Explain your diagnosis in specific clinical terms
- Detail all prior treatments tried and why they failed or were contraindicated
- Reference published clinical guidelines supporting the requested treatment
- Directly address the insurer's stated denial reason
- Explain the consequences of not receiving the treatment
Step 3: Request a Peer-to-Peer Review
Your doctor has the right to speak directly with the insurer's medical reviewer. This peer-to-peer call is often the fastest way to overturn a prior auth denial. Many denials are reversed at this stage when two clinicians talk directly about the patient's case. Encourage your doctor to request this call promptly.
Step 4: File a Formal Appeal
If peer-to-peer review fails, file a formal written appeal. Include:
- The letter of medical necessity
- Peer-reviewed research supporting the treatment
- Your complete medical records relevant to the condition
- Any prior treatment records showing step therapy compliance
Step 5: Request Expedited Review for Urgent Cases
If waiting for a standard review creates a serious risk to your health, request an expedited appeal. Insurers are required to respond to expedited appeals within 72 hours. Make clear in writing why the situation is urgent.
Important Deadlines to Know
| Appeal Type | Typical Insurer Response Deadline |
|---|---|
| Urgent/Expedited | 72 hours |
| Pre-service (non-urgent) | 15 days |
| Post-service | 30 days |
| External Review | 45–60 days (varies by state) |
If All Else Fails: External Review
For health plans subject to the ACA, a denied internal appeal on a prior auth can be taken to independent external review. This is a critical backstop — external reviewers are medical professionals with no financial stake in your insurer's bottom line. Approval rates at external review are meaningful and well worth pursuing.
Don't Accept "No" as the Final Answer
Prior authorization denials are designed, in part, to discourage patients from pursuing care. The appeals process exists precisely to correct inappropriate denials. Arm yourself with documentation, involve your doctor as an active partner, and push every level of review available to you.