Authorization in healthcare, almost always called “prior authorization” or “preauthorization,” is the process of getting approval from a health insurance company before you receive a specific treatment, procedure, or medication. If your insurer requires it and you skip this step, they can refuse to cover the cost entirely, leaving you responsible for the full bill. It applies to a wide range of services, from specialty drugs to imaging scans to certain surgeries, and it has become one of the most common friction points between patients, doctors, and insurance companies in the U.S. healthcare system.
Why Insurance Companies Require It
Prior authorization exists for two main reasons: controlling costs and ensuring treatments are backed by clinical evidence. Insurers use it to verify that a prescribed drug, procedure, or test is medically necessary and aligns with established treatment guidelines before agreeing to pay for it. In theory, this protects patients too. Requiring a second check can flag harmful drug interactions, prevent adverse events, and steer treatment toward options with stronger safety and efficacy profiles.
On the cost side, prior authorization is one of several tools insurers use to manage prescription drug and procedure spending. For medications, a common scenario involves “step therapy,” where the insurer requires you to try a less expensive, well-established drug first before approving a costlier alternative. The stated goal is not to block appropriate care but to promote use in the patient population where safety and effectiveness have been clearly demonstrated.
What Services Typically Require Authorization
The specific services that trigger prior authorization vary by insurer, plan type, and state. However, certain categories come up far more often than others:
- Advanced imaging: MRIs, CT scans, and PET scans
- Specialty medications: biologics, cancer drugs, and high-cost injectables
- Surgical procedures: spinal fusions, joint replacements, and weight-loss surgery
- Durable medical equipment: wheelchairs, CPAP machines, and prosthetics
- Mental health and substance abuse treatment: inpatient stays, residential programs
To give a concrete example, the Centers for Medicare and Medicaid Services (CMS) requires prior authorization for specific hospital outpatient procedures including eyelid surgery, cosmetic nose surgery, vein procedures, spinal neurostimulator implants, cervical spine fusions, certain spinal injections, and botulinum toxin injections. Private insurers often cast an even wider net.
How the Process Works
The process typically starts with your doctor’s office, not with you. After your physician determines you need a particular treatment, their staff submits a request to your insurance company. This request includes clinical documentation: your diagnosis, relevant medical history, lab results, imaging, and a justification for why the proposed treatment is appropriate.
The insurance company then reviews the request against its coverage criteria. These criteria come from different places depending on the insurer. Some develop standards internally based on their own utilization data. Others draw from peer-reviewed medical literature, government agencies, or medical association guidelines. Many purchase clinical criteria from third-party vendors that specialize in evidence review. This patchwork means the same treatment can be approved by one insurer and denied by another, even for patients with identical conditions.
If approved, you and your doctor get the green light to proceed, and the insurer commits to covering the service per your plan’s terms. If denied, you typically receive a reason for the denial and the option to appeal. Your doctor can also submit additional documentation or request a peer-to-peer review, which is a phone call between your physician and a physician working for the insurer.
How Long It Takes
Turnaround times have been a major source of frustration. Under a CMS rule taking effect primarily in 2026, impacted insurers will be required to respond to urgent prior authorization requests within 72 hours and standard (non-urgent) requests within seven calendar days. These are for medical items and services, and they represent a significant tightening compared to the inconsistent timelines many patients currently experience.
In practice, though, many requests take considerably longer, especially when initial submissions are denied and resubmitted with additional documentation. Each round of back-and-forth can add days or weeks. For time-sensitive conditions, these delays carry real consequences.
The Impact on Patients and Physicians
The toll of prior authorization is well documented. In a survey highlighted by the American Medical Association, 93% of physicians reported that prior authorization causes delays in patient care. Even more striking, 82% said it sometimes leads patients to abandon treatment altogether, either because they cannot wait for approval or because the process feels too burdensome to navigate. On the provider side, 89% of physicians said prior authorization contributes to professional burnout.
For patients, the experience often looks like this: you see your doctor, agree on a treatment plan, and then wait. You may not hear anything for days. If the request is denied, your doctor’s office has to spend time appealing while you remain untreated or on a less effective therapy. For conditions where timing matters, such as cancer treatment or progressive neurological disease, these delays can directly affect outcomes.
New Rules Aimed at Fixing the System
Federal regulators have moved to address some of the most persistent complaints. The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) introduces several changes taking effect in 2026. Beyond the 72-hour and seven-day response windows, the rule requires impacted insurers to provide a specific reason for any denied prior authorization decision, regardless of how the request was submitted. Insurers will also need to report standardized metrics on their authorization activity, with the first set of data due by March 31, 2026. The goal is greater transparency: patients and providers will have clearer insight into why requests are denied and how often.
At the state level, a growing number of legislatures are passing “gold carding” laws. These programs exempt physicians with consistently high approval rates from prior authorization requirements for certain services. Texas passed a gold card bill in 2022 that exempts physicians with a 90% or higher approval rate from future prior authorization for a minimum of six months. Vermont established a tiered gold carding program in 2020, and West Virginia enacted similar legislation effective in 2024. These laws are still limited in scope, often applying only to specific plan types or employer groups, but they represent a shift toward reducing administrative burden for providers who have demonstrated a track record of appropriate prescribing.
What You Can Do as a Patient
If your doctor tells you a treatment requires prior authorization, ask the office how long the process typically takes with your insurer and whether they handle the submission or if you need to do anything. Keep a record of submission dates and any reference numbers. If a request is denied, you have the right to appeal, and your insurer is required to tell you how.
Check your insurance plan’s formulary (its list of covered drugs) and its published list of services requiring authorization, usually available on the insurer’s website or by calling the member services number on your card. Knowing what requires authorization before your appointment can help you and your doctor plan ahead. Some plans also have exceptions processes for urgent situations where waiting for standard authorization could cause serious harm.
If you are caught between a denial and a treatment you need, ask your doctor’s office about a peer-to-peer review. This direct conversation between your physician and the insurer’s medical reviewer resolves a meaningful share of denials, particularly when the clinical picture is more nuanced than what paperwork alone can convey.