Jan 14, 2026
Picture this: You’re in pain. Your doctor prescribes a treatment. Then nothing. Weeks pass without a word from your insurance company.
You call, you wait, you call again. Eventually, you find out your treatment was denied because your insurer decided it wasn’t “medically necessary.”
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For many, it’s one of the most challenging parts of the U.S. health care maze: prior authorization. It’s the insurance red tape that requires your doctor to get approval before you receive certain treatments, tests or medications (1).
In theory, it’s supposed to keep costs in check and make sure care is actually needed. But in reality, it can often mean delays, denials, and endless frustration when paperwork stands between patients and the care they need.
A painful waiting game
If you’ve ever waited days, weeks or months for your doctor to get the green light from your insurance company before moving forward with treatment, you’ve likely felt the sting of priorization. And according to a recent New York Times report, this red-tape ritual is becoming a serious pain point for both doctors and patients (2).
The idea behind it seems reasonable: Insurers want to ensure treatments are medically necessary before they pay for them. But in practice, it often means delayed appointments, stalled medication refills or postponed surgeries. For patients with chronic or urgent conditions, those delays can make things worse.
The American Medical Association (AMA) warns that the wait for approval complicates life for everyone involved (3). Missed therapy windows or surgery delays can add stress, worsen symptoms and push patients into costly care they didn’t need in the first place.
Denials only add to the problem. In 2023, Medicare Advantage insurers received nearly 50 million prior authorization requests, according to the Kaiser Family Foundation (4). About 6.4% were denied in full or in part, amounting to roughly 3.2 million decisions that blocked or restricted care. Rates varied widely, with Humana denying just 3.5% and Centene rejecting about 13.6%.
Common reasons for denial include:
- A clerical error, like a typo or wrong billing code
- Missing or unclear documentation
- A treatment that isn’t covered under the plan
- Care at a hospital that’s not within the policy’s network
Whether those denials are partial or full, the outcome is the same: Patients wait longer or pay out of pocket.
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The power of the appeal
Waiting for medical approval is stressful enough, but the financial hit can be just as painful.
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Take knee replacement surgery, for example. It’s one of the most common orthopedic procedures in the country, according to CareCredit, and can cost anywhere from $14,000 to about $49,000, depending on the hospital and care required (5). If your insurer refuses to approve it, you could be stuck footing the bill.
But don’t lose hope. The AMA says that over 80% of prior authorization appeals succeed, and you don’t have to go it alone (6).
Doctors often have better success with appeals because they know what insurers look for and how to provide the right medical evidence. If you have employer-based insurance, your HR department can also step in to help review forms, resolve errors and push the case forward.
It’s not all doom and gloom. Humana says it plans to scale back its prior authorization requirements and speed up approvals by 2026, according to Kiplinger (6). And Time reports that a coalition of major insurers has pledged to standardize electronic systems and reduce services requiring pre-approval by that same year (7).
Prior authorization was meant to protect patients and rein in costs. Instead, it has often created roadblocks to timely care. Knowing how the process works, keeping documentation sharp and leaning on your doctor or HR team can improve your odds and your timeline.
With more reforms on the way, patients and providers are hoping for a system with faster approvals, fewer denials and one that puts people, not paperwork, first.
Article sources
We rely only on vetted sources and credible third-party reporting. For details, see our editorial ethics and guidelines.
AMA (1, 3, 6); New York Times (2); KFF (4); CareCredit (5); Kiplinger (6); Time (7).
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Jessica is a freelance writer with a professional background in economic development and small business consulting. She has a Bachelor of Arts in Communications and Sociology and is completing her Publishing Certificate.
