Prior Authorization for Joint Injections: Complete Step-by-Step Guide

What Is Prior Authorization and Why It Matters

Prior authorization (PA)—also called pre-authorization, pre-approval, or pre-certification—is your insurance company’s way of reviewing whether a treatment is medically necessary before you receive it.

For joint pain patients, PA requirements can mean the difference between covered treatment and a surprise bill for hundreds or thousands of dollars.

Quick Reference: Which Plans Require Prior Authorization

Always verify: PA requirements can vary by specific plan design, even within the same insurance company.

Why Insurance Companies Require Prior Authorization

The Official Reasons

Insurance companies say PA helps:

• Ensure treatments are medically necessary
• Prevent inappropriate use of expensive treatments
• Promote evidence-based care
• Control healthcare costs

The Practical Reality

PA serves multiple purposes:

• Cost control: PA creates an administrative hurdle that reduces utilization
• Medical review: Insurers verify treatments meet coverage criteria
• Step therapy enforcement: Ensures lower-cost options tried first
• Fraud prevention: Identifies patterns of unnecessary treatment

The Patient Impact

For patients, PA requirements mean:

• Treatment delays: 1-3 weeks additional wait time
• Administrative burden: Your provider’s office handles most paperwork, but you may need to provide information
• Uncertainty: Treatment plans can’t move forward until approval received
• Risk of denial: Even medically appropriate treatments may be initially denied

The Prior Authorization Process: Step-by-Step

Step 1: Verify PA Is Required (1-2 Days Before Scheduling)

Your responsibility:

1. Call your insurance company (number on back of card)

   • Ask: “Is prior authorization required for viscosupplementation?”
   • Ask: “What is the process? Who submits the request?”
   • Ask: “What documentation is needed?”
   • Ask: “How long does approval take?”

2. Confirm with your provider’s office

   • Ask: “Does my insurance require prior authorization?”
   • Ask: “Do you handle the PA process?”
   • Ask: “How long should I expect this to take?”

3. Document the information

   • Write down: Date, representative name, reference number
   • Note: Specific requirements and timelines

Step 2: Gather Required Documentation (3-7 Days)

Your provider’s office typically handles documentation, but you may need to provide:

Medical History:

• Diagnosis information (when symptoms started, severity)
• Previous treatments tried (dates and outcomes)
• Current medications
• Functional limitations (how pain affects daily activities)

Conservative Treatment Records:

• Physical therapy: Dates, number of sessions, outcome
• Medications: Names, dosages, dates used, effectiveness
• Home exercises or activity modifications
• Weight loss efforts if applicable

Diagnostic Imaging:

• X-rays showing osteoarthritis
• MRI results if available
• Reports should be in medical records

Previous Injections (if applicable):

• Dates of prior injection series
• Type of injection received
• Duration of relief
• Functional improvements

Step 3: PA Request Submission (1 Day)

Your provider’s office submits:

1. PA request form

   • Patient demographics
   • Diagnosis codes (ICD-10)
   • Procedure codes (CPT)
   • Requested treatment details

2. Medical necessity letter

   • Clinical rationale for treatment
   • Summary of conservative treatment failure
   • Expected outcomes and benefits
   • References to supporting evidence if needed

3. Supporting documentation

   • Medical records
   • Imaging reports
   • Treatment history
   • Lab results if relevant

Submission methods:

• Online portal (fastest)
• Fax
• Phone (some urgent cases)
• Mail (slowest)

Step 4: Insurance Review (3-15 Days)

Standard review timeline:

• Routine requests: 3-15 business days
• Expedited requests: 24-72 hours (if medical urgency)

What happens during review:

1. Initial screening for completeness
2. Medical review by clinical staff or physician
3. Comparison to coverage criteria
4. Decision: Approve, deny, or request more information

Possible outcomes:

• Approved: Authorization number issued, valid for specific timeframe
• Denied: Written explanation of reason, appeal rights included
• Pended: Additional information requested before decision

Step 5: Receive Authorization Decision (Same Day as Decision)

If approved:

• You or your provider receives approval notice
• Authorization number provided
• Validity period specified (typically 30-90 days)
• Approved provider and facility listed
• Save this documentation - you’ll need it

If denied:

• Written denial letter sent
• Specific reason(s) for denial included
• Appeal rights and deadlines explained
• Alternative treatment suggestions may be included

If pending:

• Notification of what additional information is needed
• Deadline for submitting information
• Timeline resets after information received

Step 6: Schedule Treatment (After Approval)

Once you receive approval:

1. Verify authorization details:

   • Authorization number
   • Approved treatment/procedure code
   • Approved provider/facility
   • Valid dates (don’t let it expire)

2. Schedule appointment

   • Provide authorization number to provider
   • Schedule within validity period
   • Confirm provider has authorization on file

3. Before treatment day:

   • Call insurance to confirm authorization is active
   • Bring insurance card and authorization number
   • Verify your provider has authorization documented

Required Documentation: What You Need

For Hyaluronic Acid (HA) Injections

Most insurance plans require evidence of:

1. Confirmed Osteoarthritis Diagnosis

• X-ray or MRI showing joint degeneration
• Clinical examination findings
• Symptom duration and severity

2. Conservative Treatment Failure Typically must document at least 3 months of:

• Physical therapy or structured home exercise program
  • Dates of sessions or program details
  • Outcome: Insufficient relief
• Medications:
  • Over-the-counter NSAIDs (ibuprofen, naproxen)
  • Or prescription NSAIDs
  • Or acetaminophen
  • Dates used, dosages, effectiveness
• Activity modifications:
  • Weight loss efforts if overweight
  • Use of assistive devices
  • Activity limitations

3. Medical Necessity Justification

• How pain affects daily function (walking, stairs, work, sleep)
• Why HA injections are appropriate now
• Expected benefits and duration of relief
• Why other treatments are insufficient

4. Treatment History (if applicable)

• Previous injection series (dates, types, outcomes)
• Why retreatment is needed
• Duration of relief from prior injections

For Cortisone Injections

Generally easier to obtain, but may still require:

• Diagnosis documentation
• Medical necessity justification
• Treatment plan

For Physical Therapy

Often requires:

• Physician referral or prescription
• Diagnosis and treatment plan
• Number of sessions requested
• Expected goals and outcomes

Common Reasons for Denial

Documentation Issues (40% of Denials)

Insufficient conservative treatment documentation:

• Solution: Provide detailed records with dates and outcomes
• Make sure to document duration (3+ months typically required)

Missing imaging evidence:

• Solution: Ensure X-rays or MRI reports are in medical records
• Images should clearly show osteoarthritis

Incomplete medical necessity justification:

• Solution: Provider should clearly explain why HA is appropriate
• Include functional limitations and expected benefits

Missing prior authorization request:

• Solution: Verify PA requirements before scheduling

Medical Necessity Issues (30% of Denials)

Treatment not meeting plan criteria:

• Solution: Review plan’s specific coverage policy
• Ensure documentation addresses each requirement

Step therapy not completed:

• Solution: Document cortisone or other required treatments tried first
• Show why they were inadequate

Treatment frequency exceeds limits:

• Solution: Ensure adequate time passed since last treatment
• Most plans require 6 months between HA injection series

Diagnosis doesn’t qualify:

• Solution: Ensure diagnosis codes match covered conditions
• Most plans cover knee OA; coverage for other joints varies

Process Issues (20% of Denials)

Out-of-network provider:

• Solution: Verify network status before treatment
• Request gap exception if preferred provider is out-of-network

Authorization expired:

• Solution: Check validity dates
• Schedule treatment within authorized timeframe
• Request extension if needed

Incorrect procedure code:

• Solution: Provider should use correct CPT codes
• Verify codes match what was authorized

Plan Coverage Issues (10% of Denials)

Treatment not covered by plan:

• Solution: Verify coverage before requesting PA
• Consider alternative treatments or out-of-pocket payment

Benefit limits exhausted:

• Solution: Check if plan has annual or lifetime limits
• May need to wait for benefit year to reset

How to Avoid Denials: Prevention Strategies

Before You Request PA

1. Read your plan documents

   • Review Evidence of Coverage or Summary Plan Description
   • Look for coverage criteria and exclusions
   • Note any step therapy or frequency requirements

2. Call your insurance

   • Verify PA requirements
   • Ask about specific documentation needed
   • Request copy of coverage policy

3. Prepare complete documentation

   • Gather all conservative treatment records
   • Ensure imaging is complete and in medical records
   • Document functional limitations clearly

During PA Submission

4. Use experienced provider office

   • Choose providers familiar with PA process
   • Ask: “How often do your PA requests get approved?”
   • Verify they’ll handle submission and follow-up

5. Submit complete request

   • Include all required documentation upfront
   • Don’t wait for plan to request additional information
   • More documentation is better than less

6. Follow up proactively

   • Call plan 3-5 days after submission
   • Verify request was received
   • Ask if additional information needed

After Submission

7. Track deadlines

   • Know when decision is due
   • Follow up if deadline passes without decision
   • Document all communications

8. Get written approval

   • Don’t rely on verbal approval
   • Get authorization number in writing
   • Verify details match what was requested

What to Do If You’re Denied

Step 1: Understand the Denial (Same Day)

1. Request written denial letter if not already received

2. Read carefully:

   • Specific reason for denial
   • What criteria wasn’t met
   • Appeal rights and deadlines
   • Additional information needed

3. Common denial reasons:

   • “Not medically necessary”
   • “Experimental or investigational”
   • “Step therapy not completed”
   • “Insufficient documentation”

Step 2: Decide Whether to Appeal (1-3 Days)

Appeal if:

• You believe you meet medical necessity criteria
• Denial was due to missing documentation you can provide
• Process error (wrong code, expired authorization)
• Step therapy requirement wasn’t communicated upfront

Don’t appeal if:

• Treatment truly isn’t covered by your plan
• You don’t meet medical necessity criteria
• Faster to pay out-of-pocket and move forward

Step 3: Gather Appeal Documentation (3-7 Days)

Essential documents:

1. Denial letter - shows what plan cited as reason
2. Medical records - complete history including:
   • Diagnosis and imaging
   • Conservative treatment attempts with dates and outcomes
   • Previous injection history if applicable
   • Functional limitations
3. Medical necessity letter from provider:
   • Why treatment is appropriate for your specific case
   • How you meet coverage criteria
   • Expected benefits
   • References to clinical evidence if helpful
4. Plan coverage policy - show how you meet criteria
5. Peer-reviewed research (if applicable)

Optional but helpful:

• Personal statement describing impact on quality of life
• Letters from other treating physicians
• Functional assessment scores (WOMAC, VAS pain scale)

Step 4: File Appeal (Within Deadline)

Know your deadline:

• Most plans: 180 days for commercial insurance
• Medicare Advantage: 60 days
• Some plans: As short as 30 days
• Don’t miss this deadline - late appeals may not be accepted

Submission methods:

• Online portal (fastest, get confirmation)
• Fax (get confirmation page)
• Mail (certified with return receipt)
• Phone (follow up in writing)

What to include:

• Completed appeal form (if required)
• Denial letter
• All supporting documentation
• Provider letter of medical necessity
• Cover letter explaining why denial should be overturned

Step 5: Wait for Appeal Decision (15-60 Days)

Standard appeal timelines:

• Commercial insurance: 30 days
• Medicare Advantage: 30 days
• Expedited appeals: 24-72 hours

During the wait:

• Call weekly for status update
• Document all communications
• Submit additional information promptly if requested

Possible outcomes:

• Approval: Treatment authorized, schedule promptly
• Partial approval: Approved with modifications
• Denial upheld: Move to next level appeal or consider alternatives

Step 6: Consider Next-Level Appeals

If internal appeal denied:

Commercial Insurance:

• External review through state insurance department
• Independent medical review
• Decision typically binding on insurer

Medicare Advantage:

• Independent Review Entity (IRE)
• Administrative Law Judge (ALJ)
• Medicare Appeals Council
• Federal Court
• Strong success rate at higher levels

Special Situations

Urgent Medical Need

If waiting for standard PA timeline would seriously harm you:

Request expedited review:

• Your provider must document urgency
• Plan must respond within 24-72 hours
• Applies when standard timeline could seriously harm health

Criteria for expedited:

• Severe pain causing inability to function
• Risk of significant functional decline
• Other urgent medical circumstances

Out-of-Network Provider

If your preferred provider isn’t in-network:

Request gap exception:

• Available when no in-network provider can meet your needs
• Must show why in-network providers aren’t adequate
• Examples: No in-network providers with specialized expertise, distance to in-network providers excessive

Documentation needed:

• Letter from provider explaining specialized care needed
• Evidence no in-network providers meet your needs
• Willingness of out-of-network provider to accept in-network rates

Treatment Already Received

If you received treatment before getting PA:

Retroactive authorization:

• Some plans allow retroactive PA requests
• Much harder to get approved
• File immediately and explain circumstances

Appeal denial:

• If retroactive PA denied, appeal claim denial
• Argue: Treatment was medically necessary, PA confusion, emergency circumstances
• Success rates are low - always get PA upfront when required

Timeline Summary: What to Expect

Total typical timeline: 1-3 weeks from PA request to treatment (if approved on first submission)

Questions to Ask Your Insurance Company

Before Requesting PA

1. “Is prior authorization required for viscosupplementation (hyaluronic acid injections)?”
2. “What specific documentation is required?”
3. “How long does the review process typically take?”
4. “Can I request expedited review if medically necessary?”
5. “What are the medical necessity criteria?”
6. “Are there step therapy requirements?”
7. “How long is authorization valid once approved?”

During PA Process

8. “Has my prior authorization request been received?”
9. “What is the status of my request?”
10. “Is any additional information needed?”
11. “When should I expect a decision?”
12. “Can you provide a reference number?”

If Denied

13. “What specific criteria did I not meet?”
14. “Can you provide a copy of the coverage policy?”
15. “What is the appeal process and deadline?”
16. “Can I submit additional documentation for reconsideration?”
17. “What are my rights if I disagree with this decision?”

Questions to Ask Your Provider’s Office

1. “Do you handle prior authorization submissions?”
2. “What is your success rate getting HA injections approved?”
3. “What information do you need from me?”
4. “How long should I expect the process to take?”
5. “Will you notify me when approval is received?”
6. “What happens if the PA is denied?”
7. “Do you handle appeals if necessary?”

Red Flags and Problems to Avoid

Provider Office Red Flags

• “Don’t worry about PA, we’ll bill later” - Recipe for denied claim and large bill
• “Just pay upfront, insurance will reimburse” - Not how PA works
• “We don’t do prior authorizations” - Find a provider who does
• Poor communication - Choose office that keeps you informed

Process Red Flags

• Scheduling treatment before PA approval - Risk of 100% out-of-pocket cost
• Verbal approval only - Always get written authorization
• Expired authorization - Verify validity dates before treatment
• Wrong provider/facility - PA may specify where treatment must occur

Resources and Contacts

Your Insurance Plan

• Member services number: On back of insurance card
• Online portal: Usually can track PA status
• Coverage policies: Often available online or by request

Medicare Resources

• Medicare: 1-800-MEDICARE (1-800-633-4227)
• Medicare.gov: Coverage information and plan finder
• State Health Insurance Assistance Program (SHIP): Free local help

State Resources

• State Insurance Department: Handles external appeals and complaints
• Find your state: NAIC Consumer Information Source

Patient Advocacy

• Patient Advocate Foundation: 1-800-532-5274
• Appeals support and assistance

Key Takeaways

1. Always verify PA requirements before scheduling treatment
2. Get written approval - never rely on verbal authorization
3. Complete documentation is critical - include all conservative treatments tried
4. Provider’s office typically handles submission - but verify they will
5. Plan ahead - PA process takes 1-3 weeks typically
6. Appeals are possible and often successful - don’t give up if denied
7. Deadlines are strict - file appeals within required timeframes
8. Treatment without PA = denial - you’ll pay 100% out-of-pocket

Related Resources

• Cigna Coverage Guide - Commercial insurance PA process
• Medicare Advantage and Joint Pain - MA plan PA requirements
• Understanding Out-of-Pocket Costs - What you’ll pay
• Medicare Coverage Guide - Original Medicare (usually no PA)
• Hyaluronic Acid Injections - Treatment overview
• How to Choose a Provider - Find PA-experienced providers