Insurance denied prior authorization. His doctor never told him he could appeal.
Kevin, 42, tore his ACL playing rec league basketball. His orthopedic surgeon ordered surgery — straightforward for a complete tear confirmed by MRI. Two weeks later, Kevin got a letter from his insurer: prior authorization denied. Reason: "not medically necessary."
His surgeon's office said they'd "try again." Another two weeks passed. Another denial. Kevin was told to just wait. Six weeks after his injury, he still hadn't had surgery.
"I have a torn ACL. There's an MRI showing it. My surgeon says I need surgery. How is an insurance company — that has never examined me — allowed to say it's not necessary?"
Kevin didn't know he had options beyond waiting for the insurer to say yes on its own timeline.
Prior authorization is a requirement that your insurer approve certain procedures before they happen. Insurers use it to reduce costs — sometimes legitimately, often not. "Not medically necessary" denials are frequently issued automatically by algorithm before a physician ever reviews the case.
The most effective tool most patients never know about is a peer-to-peer review: your doctor calls the insurance company's medical reviewer directly — physician to physician — to make the case. Studies show peer-to-peer reviews overturn prior auth denials more than 70% of the time. Most doctors' offices don't offer it unless you specifically ask.
Six weeks of delay ended with a 12-minute phone call that Kevin had to ask for himself. His surgery was scheduled the following week. The peer-to-peer review option existed the entire time.