What is prior authorization and why was yours denied?

Prior authorization is a requirement that your plan approve a medication, procedure or service before you receive it, or it will not be covered. A request is denied when the reviewer concludes the submitted paperwork did not meet the plan's written criteria for that service, which is often a documentation problem rather than a judgment that the care is wrong. Denials at this stage are appealable, and many are also fixable by resubmission with what was missing.

What is prior authorization for?

Plans use it as a gate on cost and, in their framing, on appropriateness: before agreeing to pay, the plan checks the request against criteria it has written for that drug or service. Those criteria typically ask about the diagnosis and how it was established, what has already been tried, whether a required test or specialist evaluation has happened, and whether the request fits the plan's approved indication and dosing.

The important structural fact is that nobody at the plan examines you. The reviewer sees a form, a code, and whatever notes the requesting office attached. The decision is made about a document.

Why do prior authorization requests get denied?

In practice the reasons cluster:

• Missing documentation. The criteria required a note, a lab value, an imaging report or a record of a prior trial, and it was not attached.
• A step not yet met. The plan requires a different drug or a more conservative treatment first. That is step therapy, and it has its own override path.
• Off the approved indication. The request is for a use outside the labeled or plan-approved indication, so the criteria do not obviously apply.
• Coding and administrative mismatches. Wrong code, wrong site of service, wrong provider network status, expired eligibility, or a request sent to the wrong entity, such as the plan when the drug is carved out to a pharmacy benefit manager.
• A clinical judgment. The reviewer read the same records and concluded the criteria were not met. That is a medical necessity disagreement.
• Nothing at all. A request can lapse rather than be decided, which reads to a patient as a denial and is handled differently, by pressing on the deadline.

The first three and the fifth are argued. The fourth is corrected.

How do you tell which one happened to you?

Read the denial notice for the phrase it uses, then ask the plan in writing for the specific criteria applied and the reviewer's rationale. Plans generally have to give you the documents they relied on, free of charge, and it is hard to answer criteria you have not seen.

If the notice says the request was incomplete, ask exactly what was missing. That answer often turns a multi-week appeal into a same-week resubmission.

What can your clinician do?

Two things, quickly. A peer to peer review is a direct conversation between your treating clinician and the plan's medical reviewer, and for prior authorization it is frequently the fastest route to a different answer, because the case can be explained rather than inferred from a form. The office can request one as soon as a denial arrives.

Second, the office can resubmit with the missing element attached. If the criteria wanted six weeks of documented conservative therapy and the chart has eight, the chart page is the whole argument.

How long does a decision take, and can it be sped up?

Standard prior authorization decisions are commonly made within a couple of weeks, and expedited requests within roughly seventy two hours, though the governing timetable is in your plan documents and varies by coverage type and state. Medicare Advantage, Medicaid managed care and commercial plans each run on their own rules.

Ask for expedited review where a delay would seriously jeopardize your health or your ability to regain function. The request has to be made, not assumed, and your clinician's office can make it on your behalf.

What should the appeal actually argue?

Against the plan's own criteria, in the plan's own order. A strong prior authorization appeal usually does four things:

1. Establishes the diagnosis with the objective evidence the criteria ask for.
2. Documents the history the reviewer never saw: what was tried, for how long, at what dose, and what happened.
3. Cites the guideline, label or literature supporting the requested care for this indication, so nothing rests on assertion.
4. Explains clinically why the plan's suggested alternative does not fit this patient.

Attach an index. A reviewer who can find the note is a reviewer who can act on it.

What if the appeal is denied too?

Internal appeal is normally not the last step. Most people also have the right to an independent external review, by a reviewer with no financial relationship to the plan, whose decision binds the plan. The federal summary is on HealthCare.gov, and the deadline to request it is in the letter denying the internal appeal.

Appeals are rare. In KFF's analysis of federal HealthCare.gov data, consumers appealed 376,508 of 86 million denied in-network claims in 2023, under 1% (KFF, January 2025).

Where to start today

If the denial arrived in the last day or two, work through what to do in the next 48 hours first, then read the mechanics of how an appeal is built. If you want the specifics of how Cove Health answers this kind of decision, that is on the prior authorization page.

A licensed physician can review your records, tell you candidly whether the case has merit, and write the letter, for you or for someone you love. What the plan decides is the plan's; what goes in front of it does not have to be left to chance.