Prior authorization: how to get the yes without the runaround

Prior authorization is the insurer's requirement that certain care — an expensive drug, an MRI, a surgery, a hospital stay — be approved before you get it. In principle it exists to prevent unnecessary care; in practice it's one of the biggest sources of delay, denial, and frustration in American medicine. The good news: the process runs on rules and deadlines, and knowing them turns a bureaucratic wall into a series of steps you can actually work.

What needs prior authorization

• High-cost imaging (MRI, CT, PET scans) and non-emergency surgeries.
• Specialty and brand-name drugs, especially newer biologics and anything with a cheaper alternative the plan prefers.
• Planned hospital admissions and some outpatient procedures.
• Durable medical equipment, home health, and skilled nursing.
• 'Step therapy' drugs, where the plan requires you to try (and fail) a cheaper medication first.

The timelines you can hold them to

Insurers must respond within set windows: for standard requests, typically a few days to two weeks depending on your plan type and state; for urgent requests (where a delay could seriously harm your health), usually 72 hours or less. If a delay is dangerous, your doctor can mark the request 'expedited' or 'urgent,' which triggers the faster clock. Many states and recent federal rules have tightened these deadlines further — if an insurer blows past its own timeline, that's grounds to escalate.

When it's denied: the peer-to-peer is your fastest tool

A prior authorization denial is not final — and it's usually not even a doctor's decision. Most are automated checks against plan criteria. The single most effective response is a peer-to-peer review: a direct phone call between your prescribing physician and the insurer's medical director. These conversations reverse a large share of denials in one call, because your doctor can explain your specific situation against the plan's own guidelines. Ask your provider to request a peer-to-peer immediately when a denial arrives.

If the peer-to-peer fails: the formal appeal

1. 1
   Get the denial reason in writing

   The denial must state the specific reason and cite the plan provision it relied on. You're entitled to the medical policy the decision used — request it.

2. 2
   File an internal appeal

   Submit a written appeal (typically within 180 days) with a physician's letter of medical necessity addressing the plan's criteria point by point. Attach records showing you meet them.

3. 3
   Escalate to external review

   If the internal appeal fails, request an independent external review — binding on the insurer. 'Experimental/investigational' and medical-necessity denials do well here, because outside physicians apply current evidence rather than the plan's dated policy.

4. 4
   Ask about a formulary exception for drugs

   For medication denials, your doctor can separately request a formulary or step-therapy exception with a medical-necessity letter — often approved when lower-tier options failed or can't be used.

The bottom line

Prior authorization is a process, not a verdict. Confirm your provider actually submitted the request and hold the insurer to its response deadline; mark urgent cases urgent; and when a denial lands, reach for the peer-to-peer review first, then the internal appeal and binding external review. Most denials are automated filters that check whether anyone will push back — so push back, in writing, on schedule. The care was appropriate; the paperwork just needs a human to say so.