What Is Prior Authorization? A Patient's Guide

If your doctor recommends a treatment like gel injections for your knee, you might hear: “We need to get prior authorization first.” This can feel confusing or frustrating, but understanding the process helps it go smoothly.

What Is Prior Authorization?

Prior authorization (sometimes called “pre-authorization” or “pre-approval”) is when your insurance company reviews a treatment before you receive it. They decide whether they’ll cover the cost based on your specific situation.

Think of it like getting permission before making a purchase on a company credit card. The insurance company wants to confirm the treatment is:

• Medically necessary for your condition
• Appropriate based on your health history
• Covered under your specific plan

Without prior authorization for treatments that require it, your insurance may refuse to pay - leaving you with the full bill.

Why Do Insurance Companies Require It?

Insurance companies use prior authorization for several reasons:

Cost control - They want to make sure expensive treatments are truly needed before paying for them.

Medical necessity - Prior authorization confirms that your doctor believes the treatment is the right choice for you, not just a preference.

Step therapy compliance - Some treatments require you to try simpler options first (like physical therapy before injections). Prior authorization verifies you’ve completed those steps.

Safety checks - The review can catch potential problems, like drug interactions or treatments that aren’t right for your condition.

While the process can feel like a hurdle, it exists to manage healthcare costs and ensure appropriate care.

What Treatments Typically Need Prior Authorization?

Not every doctor visit needs pre-approval. Prior authorization is usually required for:

• Hyaluronic acid (gel) injections - Most private insurers require it
• MRIs and CT scans - Especially for joints and spine
• Specialty medications - Injectable drugs, biologics
• Certain surgeries - Including joint replacements
• Durable medical equipment - Knee braces, walkers

Good news for Medicare patients: Original Medicare (Parts A and B) typically does not require prior authorization for gel injections. However, Medicare Advantage plans often do. Check your specific plan.

Most private insurers - including BCBS, UnitedHealthcare, Aetna, Cigna, and Humana - require prior authorization for hyaluronic acid injections. Learn more about BCBS coverage requirements.

How the Process Works

Here’s what happens step by step:

You usually don’t need to do anything during this process. Your doctor’s office handles the paperwork. But you can always call your insurance to check the status.

How Long Does It Take?

Timing varies by insurance company and treatment type:

Some insurance companies offer faster electronic approvals that can come through the same day. Ask your doctor’s office if electronic submission is available.

Tip: If your pain is severe or the delay could harm your health, ask your doctor to request an “urgent” or “expedited” review. Insurance companies must respond faster in urgent situations.

What If It’s Denied?

A denial isn’t the end of the road. Many denials are overturned on appeal.

Your appeal rights:

1. Ask why - Request the specific reason for denial in writing
2. Gather documentation - Your doctor can provide additional medical records
3. Submit an appeal - You typically have 60-180 days to appeal
4. Escalate if needed - Most plans have multiple appeal levels

Studies show that 40-50% of prior authorization denials are overturned on appeal when patients and doctors provide additional information.

For detailed guidance on appealing gel injection denials, read our prior authorization guide for gel injections.

Tips for a Smooth Process

Questions to ask your doctor’s office:

• “Do you need prior authorization for this treatment?”
• “How long does approval usually take?”
• “Will you handle the paperwork, or do I need to do something?”
• “What happens if it’s denied?”

The Bottom Line

Prior authorization is simply your insurance company’s way of reviewing a treatment before they agree to pay for it. While it can add a few days to getting treatment, understanding the process helps you navigate it successfully.

The most important thing to remember: your doctor’s office handles most of the work. Your job is to make sure your medical records are complete and to follow up if you don’t hear back within the expected timeframe.

If your gel injection or other treatment requires prior authorization, don’t let it discourage you. With proper documentation, most requests are approved - and denials can often be overturned on appeal.