Prior authorization (or prior auth) is approval your insurance requires before covering certain treatments. Your doctor must submit documentation proving the treatment is medically necessary before your insurance will agree to pay for procedures like gel injections.

Requirements vary by insurer, but prior auth is commonly required for hyaluronic acid injections, PRP therapy, and certain imaging studies. Some Medicare Advantage plans require it for treatments that Original Medicare covers automatically. Always verify with your specific plan.

Standard prior auth requests typically take 3-5 business days for non-urgent treatments. Urgent requests may be processed in 24-72 hours. Some insurers take up to 15 days for complex cases. Your doctor's office should follow up if you don't hear back within a week.

Insurers typically require your diagnosis codes, documentation of failed conservative treatments (like physical therapy or medications), recent X-rays showing arthritis severity, and your doctor's notes explaining why the treatment is medically necessary.

Most insurers require step therapy, meaning you must try and fail less expensive treatments first. This often includes 4-6 weeks of physical therapy, over-the-counter pain medications, and sometimes cortisone injections before they will authorize gel injections.

If denied, you have the right to appeal. Your doctor can request a peer-to-peer review with the insurance company's medical director. About 50% of initial denials are overturned on appeal, so don't give up after the first denial.

Your doctor typically initiates the appeal by providing additional documentation. You can also submit a written appeal yourself. Request the specific reason for denial in writing, then address those concerns directly. Include any supporting medical records or studies.

Yes, your doctor can request a peer-to-peer review to discuss your case directly with the insurance company's reviewing physician. This is often more effective than written appeals because your doctor can explain the medical necessity in detail.

Original Medicare (Parts A and B) generally does not require prior authorization for hyaluronic acid injections. However, Medicare Advantage plans can add their own prior auth requirements. Check your specific plan's rules before scheduling treatment.

Common denial reasons include incomplete documentation, not meeting step therapy requirements, requesting a non-preferred brand, or the insurer determining treatment is not medically necessary. Always request the specific denial reason in writing to guide your appeal.

Prior authorizations typically last for a specific timeframe, often 90 days to one year. If you need ongoing treatment beyond that period, your doctor must submit a new prior auth request. Ask your insurer about the authorization period when approved.

Starting treatment without prior auth approval is risky. If authorization is denied, you will be responsible for the full cost. Some providers will not proceed without approval. In emergencies, insurers may approve retroactive authorization, but this is not guaranteed.

A step therapy exception allows you to skip required preliminary treatments if they are not appropriate for your condition. Reasons include allergies to first-line medications, prior unsuccessful treatment, or contraindications. Your doctor must document why the exception is needed.

Prior authorization means your insurer agrees to cover the treatment if it is performed as specified. However, you are still responsible for your deductible, copays, or coinsurance. Prior auth does not mean treatment is free, just that it is covered.

Ensure your doctor submits complete documentation the first time. Ask your doctor's office to mark the request as urgent if appropriate. Follow up with both your doctor's office and insurer every few days. Request electronic submission if available.

Your doctor's office typically handles prior authorization submissions. However, you should confirm they have submitted the request and follow up on the status. Some patients find it helpful to track the process themselves, especially for time-sensitive treatments.

For urgent medical needs, insurers must process prior auth requests within 24-72 hours. Your doctor should mark the request as urgent and explain why immediate treatment is necessary. Urgent requests require documentation that delay could harm your health.

Yes, after exhausting internal appeals, you can request an independent external review. An outside physician reviews your case without influence from your insurer. External reviews are binding, meaning the insurer must follow the decision. Your denial letter explains how to request this.

Yes, insurers may require prior auth for specific brands of hyaluronic acid even if they cover the treatment category. Your plan may have preferred brands that do not require prior auth, while non-preferred brands need additional approval and may cost more.