Prior Authorization

Extended Definition

Prior authorization (PA), also called pre-authorization or pre-approval, is a requirement that your doctor get permission from your insurance company before providing certain treatments or services.

Why It Exists

Insurance companies use PA to:

• Ensure treatments meet coverage criteria
• Confirm medical necessity
• Control costs
• Direct patients to preferred options

Treatments Often Requiring PA

For joint pain:

• Hyaluronic acid injections (especially MA plans)
• MRI and CT scans
• Extended physical therapy
• Specialty medications
• DME items
• Certain surgical procedures

The PA Process

1. Doctor submits request with clinical documentation
2. Insurance reviews (usually 1-5 business days)
3. Decision issued: Approved, denied, or more info needed
4. If denied: Appeal rights available

Tips for Smooth PA

For Patients:

• Ask if PA is required before scheduling
• Provide all requested medical records
• Follow up if decision is delayed
• Know your plan’s timeline requirements

What Doctors Provide:

• Diagnosis codes (ICD-10)
• Medical necessity documentation
• Prior treatment history
• Clinical notes supporting request

If Prior Authorization Is Denied

You have the right to appeal:

1. Internal appeal - Insurance reviews again
2. External review - Independent reviewer decides
3. Expedited review - For urgent situations

Traditional Medicare vs. MA

Situation	Traditional Medicare	Medicare Advantage
HA injections	Usually no PA needed	Often requires PA
Physical therapy	No PA	May require PA after X visits
Imaging	Usually no PA	Often requires PA