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Why Insurance Companies Are Making It Harder for Patients to Get Care
Prior authorizations, denials and delays are now a routine part of getting treatment. Here’s what’s happening — and what you can do about it.
This article is general health information written by our editors from the sources listed below. It has not yet been medically reviewed — see our medical review policy. It is not advice for your situation.
You finally saw a specialist about the pain that’s been wearing you down for months. You left the appointment with a plan — and, for the first time in a long time, a little hope.
Then you waited. A week. Two. And then a letter arrived from your insurance company with a phrase you may come to know well: “not medically necessary.”
If that sounds familiar, you’re far from alone. For many patients, the hardest part of getting care is no longer finding the right doctor — it’s getting the treatment approved.
What is prior authorization?
Prior authorization (sometimes called pre-authorization or pre-certification) means your health plan must approve a test, medication or procedure before it agrees to pay for it.
Insurers say the process helps control costs and avoid unnecessary care. Doctors and patients often say it does something else too: it adds paperwork, waiting and uncertainty at exactly the moment someone needs help.
For people with back and neck pain, prior authorization is common for MRIs, many injections, radiofrequency ablation, spinal cord stimulation and other procedures.
Why requests get denied
A denial doesn’t always mean you don’t need the treatment. Common reasons include:
- Missing or incomplete records — the insurer says it didn’t receive enough documentation.
- “Step therapy” rules — the plan wants you to try something else first, such as physical therapy or medication, for a set length of time.
- Coding or paperwork errors — a small mistake on a form can stop a request.
- Plan-specific criteria — each insurer has its own written rules for what it considers medically necessary.
“A denial letter is often the start of a process — not the end of the road.”
The real cost of delay
Waiting weeks for an answer isn’t just frustrating. For someone in significant pain, it can mean more missed work, more sleepless nights and more time relying on medications they’d rather not take. Some patients give up on treatment altogether.
There has been some movement on this. Under a federal rule that took effect in 2026, many Medicare Advantage, Medicaid and CHIP plans must return standard prior authorization decisions within seven calendar days — 72 hours for urgent requests — and give a specific reason when they deny one. Rules for other plans vary, so it’s worth asking yours what timelines apply.
What you can do: six steps
- Get the reason in writing. Ask your insurer for the denial letter and the specific policy or criteria it relied on.
- Talk to your doctor’s office. Many denials are resolved by sending missing records. Your doctor can also request a “peer-to-peer” call with the insurer’s medical reviewer.
- File an internal appeal. Your plan must tell you how and by when. For most plans covered by the Affordable Care Act, you have up to 180 days from the denial to file. Include a letter from your doctor explaining why the treatment is needed.
- Ask for an expedited review if it’s urgent. If waiting could seriously harm your health, say so — urgent appeals move faster.
- Request an external review. If your internal appeal is denied, most plans must let an independent reviewer look at the decision.
- Contact your state regulator. The Oklahoma Insurance Department, the Texas Department of Insurance and New Mexico’s Office of Superintendent of Insurance all help consumers with insurance complaints.
Keep a simple paper trail
Write down the date, the name of everyone you speak with and any reference numbers. Save every letter. If your case goes to appeal, that record helps.
Why the practice you choose matters
Getting treatment approved is easier when your doctor’s team knows what each insurer looks for and documents your care carefully from the very first visit.
At SEVA Healthcare, staff handle authorization requests as part of your care and keep you informed along the way. Approval decisions are always made by your insurer, and coverage varies from plan to plan — but you shouldn’t have to navigate the process alone.
Learn more on SEVApedia
Related reading: Top 5 pain procedures doctors recommend.
Frequently asked questions
What is prior authorization?
It’s approval your health plan requires before it will pay for certain tests, medications or procedures. Your doctor’s office usually submits the request.
Can I appeal an insurance denial?
In most cases, yes. Your plan must explain how to file an internal appeal and the deadline. For most Affordable Care Act plans, you have up to 180 days from the denial.
What is an external review?
If your plan upholds its denial after an internal appeal, you can usually ask an independent third party to review the decision. If the reviewer sides with you, the plan generally must follow that decision.
How long does prior authorization take?
It varies by plan. Under a federal rule that took effect in 2026, many Medicare Advantage, Medicaid and CHIP plans must decide standard requests within seven calendar days and urgent requests within 72 hours.
This article is sponsored content by SEVA Healthcare and is for general information only — it is not medical or legal advice. Treatment options depend on an individual evaluation, and results vary from person to person. In an emergency, call 911. Spotted an error? See our corrections policy.
