An insurer ruled West Virginia dad’s $50,000 cancer treatment ‘not medically necessary.’ He died waiting. Many Americans face the same system

Four appeals to Tennant's insurer — the Public Employees Insurance Agency of West Virginia, which partners with UnitedHealthcare — were denied. The treatment would have cost the Tennant family $50,000 out-of-pocket.

"The insurance company's decision did not simply delay care. It closed doors," his widow, Becky, told KFF Health News (1).

After KFF and NBC contacted the insurer about the denial, the decision was reversed — but it was too late. Tennant's condition had deteriorated to the point where he was no longer a candidate for the treatment. He died last September.

A larger problem

But this isn't a rare occurrence. It's the result of a process in the health care system called prior authorization, which requires health care professionals to get approval before a treatment, service or drug qualifies for payment.

Almost all enrollees (99%) in Medicare Advantage require prior authorization for some services (3).

While the process was designed to limit fraud and control costs, it's instead become "a confusing maze that denies or delays care, burdens physicians with paperwork, and perpetuates racial disparities," according to KFF Health News (4).

KFF reports that it's "heard from hundreds of patients in recent years who claim that they or someone in their family has been harmed by prior authorization" (5).

A survey by the American Medical Association (AMA) found that almost 1 in 3 (31%) physicians say prior authorizations are often or always denied. More than 1 in 4 (29%) report that this has "led to a serious adverse event for a patient in their care," including permanent impairment, disability or even death (6).

The vast majority (93%) of patients who require prior authorization face care delays, while 82% end up abandoning the recommended course of treatment (6).

In some cases, health insurers may generate profits by denying high-cost care while still collecting premiums, according to a 2024 U.S. Senate subcommittee investigation. The report points to UnitedHealthcare, Humana and CVS, which each denied prior authorization requests for post-acute care between 2019 and 2022 "at far higher rates than they did for other types of care" (7).

There's also concern that insurers using AI to make automated decisions will lead to more prior authorization denials (8).

To address these issues, a voluntary initiative was announced last year among a group of health insurance companies, aimed at speeding up the review process and making it easier to navigate (9). But, since the initiative is voluntary, it has its limitations. And, as a KFF poll shows, few Americans think their insurer will follow through (10).

At a state level, more than 30 states have passed laws in an attempt to better manage prior authorization (11).

Appealing a health decision

Half of insured adults (51%) have been required to get prior authorization before receiving a treatment, service or medication they needed in the previous two years, according to a KFF poll. Among all insured adults, close to 3 in 10 (29%) say their insurer has delayed or denied their prior authorization claim (10).

The problem is you may not realize you require prior authorization until you're denied treatment.