When a doctor tells you that you need a procedure and your insurance company tells you that the procedure is not medically necessary, you are not having a medical disagreement. You are having a financial one. The determination of medical necessity, which sounds like a clinical judgment made by someone with a medical degree who has reviewed your case, is in practice often a coverage decision made by a reviewer who may or may not be a physician, working from a set of criteria that the insurance company developed and controls, with a financial incentive to say no.
This is not a fringe critique. It is documented in the lawsuits, in the congressional testimony, in the state insurance commissioner reports, and in the investigations that major insurers have faced over the past decade. The practice of prior authorization, which requires insurer approval before receiving care, has expanded dramatically in scope over the past twenty years, and the denial rate data, where it is available, shows patterns that are not easily explained by clinical variation.
What happens when you appeal? In most states, you have the right to an external review. The external review processes are inconsistent, underfunded, and in some states effectively inaccessible to people who are simultaneously sick and fighting paperwork. The patients most likely to win an appeal are the ones with the time and energy to fight the paperwork. Seriously ill people often do not have both.
The prior authorization burden has also metastasized into physician practice in ways that have accelerated the burnout crisis in medicine. The time doctors and their staff spend seeking approvals for care that they have already determined is necessary is time not spent on patients. We looked at the denial rate data and at what several states have actually done to push back, because some of them have moved in ways that work. That’s more useful than another round of federal testimony that goes nowhere.