Prior Authorization for Gel Injections: What You Need to Know

If your doctor recommends hyaluronic acid (HA) injections for knee osteoarthritis, you may need to navigate an insurance process called prior authorization before receiving treatment. This step can feel frustrating, but understanding how it works puts you in control of the process.

This guide explains what prior authorization means, why insurers require it, and exactly what you need to do to get your treatment approved.

Key Takeaways

• Most insurance plans require prior authorization before covering gel injections
• Step therapy means you must try lower-cost treatments first
• Common requirements include X-ray confirmation of osteoarthritis and failed conservative treatments
• Prior authorization typically takes 1-2 weeks to process
• Denied requests can be appealed, often successfully with proper documentation
• Working closely with your doctor’s office is the key to a smooth process

What Is Prior Authorization?

Prior authorization (sometimes called “pre-approval” or “pre-certification”) is a process where your insurance company reviews a treatment request before agreeing to pay for it. Think of it as your insurer asking your doctor to explain why you need a specific treatment.

When your doctor submits a prior authorization request for gel injections, they’re essentially making a case that this treatment is medically necessary for your condition. The insurance company then reviews the information and decides whether to approve coverage.

What prior authorization involves:

• Your doctor submits medical records and treatment history
• The insurer reviews your case against their coverage criteria
• A decision is made to approve, deny, or request more information
• If approved, you can schedule your treatment

This process exists because gel injections are more expensive than first-line treatments like over-the-counter pain relievers. Insurance companies want to ensure patients have tried simpler options first and that the treatment is appropriate for their specific situation.

Why Insurance Requires Prior Authorization for Gel Injections

Insurance companies have several reasons for requiring prior authorization before covering viscosupplementation:

Cost management: A series of HA injections can cost $500 to $1,500 or more. Insurers want to confirm you’ve tried less expensive treatments that might work just as well for your situation.

Medical appropriateness: Gel injections work best for certain types and stages of osteoarthritis. Prior authorization helps ensure you’re a good candidate for the treatment.

Documentation requirements: Medicare and many private insurers have specific criteria that must be met. Prior authorization creates a paper trail showing these criteria are satisfied.

Utilization review: Insurers track treatment patterns to identify overuse or inappropriate prescribing. Prior authorization is one tool in this process.

While this process can feel like a barrier, it often works in your favor. When your treatment is pre-approved, you have certainty about coverage before the procedure rather than facing a surprise denial afterward.

What Is Step Therapy?

Step therapy is a coverage policy that requires you to try lower-cost or first-line treatments before your insurance will approve more expensive options like gel injections. It’s sometimes called “fail first” because you must demonstrate that initial treatments didn’t adequately relieve your symptoms.

Typical step therapy requirements for gel injections:

1. First step: Over-the-counter pain relievers (acetaminophen, ibuprofen, naproxen)
2. Second step: Physical therapy or exercise program
3. Third step: Lifestyle modifications (weight management, activity changes)
4. Fourth step: Cortisone injection
5. Final step: Gel injections (after steps 1-4 have been tried or ruled out)

Not every plan requires all these steps, and the order may vary. Some insurers accept documented medical reasons why you can’t try certain steps. For example, if you have kidney disease and shouldn’t take NSAIDs, that counts as a valid reason to skip that step.

How to document failed treatment:

When a treatment doesn’t work for you, make sure your medical record reflects:

• What you tried and for how long
• Your pain levels before and after
• Any side effects you experienced
• Why you and your doctor decided to move on

This documentation becomes crucial when your doctor submits the prior authorization request.

What You Need to Qualify for Coverage

Insurance companies have specific criteria for approving gel injection coverage. While exact requirements vary by plan, most require documentation of these elements:

Confirmed Diagnosis of Osteoarthritis

Your insurer will require objective evidence that you have osteoarthritis in the joint being treated. This typically means:

• X-ray showing joint space narrowing, bone spurs, or other OA signs
• MRI results (sometimes required, often not)
• Clinical examination findings documented by your doctor

Tip: If you haven’t had imaging in the past year, ask your doctor if updated X-rays would strengthen your prior authorization request.

Failed Conservative Treatments

You’ll need to show that you’ve tried—and not gotten adequate relief from—two to three conservative treatments. What counts as “tried” typically means:

Pain medications:

• Used acetaminophen consistently for 4-6 weeks
• Tried NSAIDs (ibuprofen, naproxen) if medically appropriate
• Documented that pain persisted despite medication

Physical therapy:

• Completed a course of PT (usually 4-6 weeks minimum)
• Participated in prescribed exercises
• Noted improvement was inadequate or temporary

Lifestyle modifications:

• Attempted weight loss if overweight
• Modified activities that aggravate the joint
• Used assistive devices (cane, brace) as recommended

Cortisone Injection (or Documented Contraindication)

Many insurers require that you’ve tried a corticosteroid injection before approving gel injections. If cortisone isn’t appropriate for you, your doctor can document why:

• Diabetes that makes blood sugar control difficult after steroids
• Previous adverse reaction to cortisone
• Cortisone tried and provided insufficient or short-lasting relief
• Other medical reasons steroids are contraindicated

Documentation of Pain Severity

Your insurer wants to know that your pain significantly impacts your daily life. Your doctor may use standardized assessment tools:

• VAS (Visual Analog Scale): Rating pain from 0-10
• WOMAC score: Measures pain, stiffness, and physical function
• Functional limitations: Difficulty walking, climbing stairs, or performing daily activities

Tip: Be specific when describing your pain to your doctor. Instead of saying “my knee hurts,” explain that you can’t walk more than one block, can’t climb stairs without holding the railing, or wake up at night from pain.

How Long Does Prior Authorization Take?

The timeline for prior authorization varies by insurance plan and complexity of your case:

Typical processing times:

• Standard requests: 5-14 business days
• Expedited/urgent requests: 24-72 hours
• Requests needing additional information: Add 1-2 weeks

What affects timing:

• How complete the initial submission is
• Whether your insurer requests additional documentation
• Your plan’s specific review process
• Whether your case requires medical director review

Expedited review: If your doctor determines that the standard timeline could seriously harm your health, they can request expedited review. This is usually reserved for urgent situations, not routine knee OA treatment.

What to expect:

1. Your doctor’s office submits the request (Day 1)
2. Insurance acknowledges receipt (Days 1-3)
3. Review period (Days 3-10)
4. Decision communicated to doctor’s office (Days 7-14)
5. You’re notified and can schedule treatment

Tip: Ask your doctor’s office to notify you when they submit the request and when they receive the decision. This keeps you informed and allows you to follow up if there are delays.

What to Do If Your Prior Authorization Is Denied

A denial isn’t the end of the road. Many prior authorization denials are overturned on appeal, especially when additional documentation is provided.

Step 1: Understand the Reason for Denial

Your denial letter must explain why coverage was denied. Common reasons include:

• Incomplete documentation: Missing records or test results
• Step therapy not completed: Haven’t tried required first-line treatments
• Medical necessity not established: Insurer doesn’t think gel injections are appropriate
• Out-of-network provider: Doctor isn’t in your plan’s network
• Prior authorization obtained incorrectly: Paperwork errors

Step 2: Review Your Options

Most denial letters explain your appeal rights. You typically have:

• 30-180 days to file an appeal (varies by plan and state)
• The right to submit additional information
• The option to request an expedited appeal if medically necessary
• Access to an external review if internal appeals fail

Step 3: Work With Your Doctor’s Office

Your doctor’s office handles most of the appeal process. They can:

• Request a peer-to-peer review (your doctor speaks directly with the insurance company’s medical reviewer)
• Submit additional documentation addressing the denial reason
• Write a letter of medical necessity explaining why gel injections are appropriate for you
• Cite clinical studies or guidelines supporting treatment

Step 4: File a Formal Appeal

If initial efforts don’t resolve the denial:

1. Submit a written appeal letter
2. Include all relevant medical records
3. Add a letter of medical necessity from your doctor
4. Reference your plan’s coverage criteria and explain how you meet them
5. Include any peer-reviewed research supporting gel injections for your situation

Appeal timelines:

• First-level appeal decision: Usually 30-60 days
• Second-level appeal (if needed): Additional 30-60 days
• External review: Varies by state, typically 45-60 days

Step 5: Consider External Review

If your internal appeals are denied, you may have the right to an external review by an independent third party. This reviewer isn’t employed by your insurance company and provides an unbiased assessment.

Medicare beneficiaries have specific appeal rights through the Medicare appeals process, which can go up to an Administrative Law Judge if needed.

Checklist: Preparing for Prior Authorization

Use this checklist to help ensure a smooth prior authorization process:

Before Your Appointment:

• Gather records of all treatments you’ve tried for knee pain
• Note when you tried each treatment and for how long
• Write down how each treatment affected your pain
• List any side effects you experienced
• Bring any imaging results (X-rays, MRIs) from other providers

At Your Appointment:

• Be specific about your pain level (use 0-10 scale)
• Describe how pain affects daily activities (walking, stairs, sleep)
• Mention all treatments you’ve tried, even ones from years ago
• Ask if any documentation is missing
• Confirm your doctor’s office will handle prior authorization

After Your Appointment:

• Ask when the prior authorization will be submitted
• Get the contact number for your doctor’s billing/authorization staff
• Know your insurance company’s phone number and member ID
• Ask how you’ll be notified of the decision
• Understand the timeline for approval or next steps

If You Receive a Denial:

• Read the denial letter carefully
• Note the deadline for filing an appeal
• Contact your doctor’s office immediately
• Ask about peer-to-peer review options
• Keep copies of all correspondence

Tips for Prior Authorization Success

1. Work closely with your doctor’s office. The billing and authorization staff at your doctor’s office navigate these processes daily. They know what documentation your specific insurer requires and how to present your case effectively.

2. Keep detailed records. Document every treatment you’ve tried, including dates, duration, and results. This information is essential for demonstrating failed conservative therapy.

3. Bring imaging to your appointment. If you’ve had X-rays or MRIs at other facilities, bring copies. This saves time and ensures your doctor has all the evidence needed.

4. Be specific about your pain and limitations. Vague descriptions like “my knee hurts” are less compelling than specific examples: “I can only walk two blocks before I need to rest” or “I haven’t been able to play with my grandchildren in six months.”

5. Know your plan’s specific requirements. Call the number on your insurance card and ask what’s required for gel injection coverage. Some plans have unique requirements beyond the standard criteria.

6. Don’t give up after a denial. Many denials are overturned on appeal. If gel injections are appropriate for your condition, persistence often pays off.

7. Ask about peer-to-peer review. If your prior authorization is denied, your doctor can often speak directly with the insurance company’s medical reviewer. This physician-to-physician conversation resolves many cases.

Frequently Asked Questions

How long is a prior authorization valid?

Most prior authorizations are valid for 60-90 days, though some plans approve for longer periods. If you don’t schedule your treatment within this window, you may need to obtain a new authorization.

Can my doctor’s office start the process before I’m seen?

Typically no. Your doctor needs to examine you and document medical necessity before submitting a prior authorization. However, you can help by gathering records of previous treatments ahead of time.

What if I need both knees treated?

Each knee is usually authorized separately. Your doctor may submit both requests at the same time, or treat one knee first to document your response before seeking approval for the second.

Does Medicare require prior authorization for gel injections?

Original Medicare (Parts A and B) generally does not require prior authorization, but your doctor must still document medical necessity. Medicare Advantage plans often do require prior authorization.

Can I pay out of pocket if my prior authorization is denied?

Yes, you can choose to pay for treatment yourself if your insurance won’t cover it. However, consider appealing first, especially if gel injections are medically appropriate for your situation. A series of HA injections typically costs $500-$1,500 when paying out of pocket.

What’s the difference between prior authorization and pre-certification?

These terms are often used interchangeably. Some insurers use “pre-certification” for verifying coverage and “prior authorization” for getting approval for specific treatments. Ask your insurance company which term applies to your situation.

---

Moving Forward

Prior authorization can feel like an obstacle between you and pain relief, but understanding the process gives you the power to navigate it successfully. The key is working closely with your doctor’s office, keeping thorough records of your treatment history, and being prepared to appeal if necessary.

Most patients who meet the medical criteria for gel injections ultimately receive coverage approval. If your osteoarthritis is confirmed by imaging, you’ve tried conservative treatments without adequate relief, and you’re a good candidate for viscosupplementation, the prior authorization process is simply about documenting what you and your doctor already know: gel injections are the right next step for your care.

Talk with your doctor about whether gel injections might be appropriate for your knee pain, and ask their staff to walk you through your specific insurance plan’s prior authorization requirements.

---

This article is for informational purposes only and does not constitute medical or insurance advice. Coverage requirements vary by insurance plan and state. Always consult with your healthcare provider and insurance company for guidance specific to your situation.

---

Related Resources

Insurance Cluster

• Does Medicare Cover Gel Injections? 2026 Guide
• Why 30% of Insurance Plans Don’t Cover Gel Injections
• Gel Injections vs Knee Replacement: Cost Comparison

Understanding the Treatment

• The FDA-Approved Treatment 80% of Patients Have Never Heard Of
• The Clinical Evidence: What 6,000+ Patients Show
• How Long Do Gel Injections Last?

Why Coverage Varies

• AAOS vs OARSI: Why Medical Guidelines Disagree on Gel Injections
• Why Your Doctor May Not Have Mentioned Gel Injections

Hub Pages

• What Is Viscosupplementation?
• Hyaluronic Acid Injections: Treatment Guide