What medical services require prior authorization?

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📋 Common Medical Services Requiring Prior Authorization

Prior authorization is health plan approval required before receiving specific non-emergency treatments or services so the insurer agrees to pay.

🏥 Advanced Imaging & Diagnostics

  • 🩻 CT Scans: Non-emergency computed tomography scans
  • 🧲 MRIs: Magnetic resonance imaging scans
  • ☢️ PET Scans: Positron emission tomography scans

🩺 Hospital & Surgical Procedures

  • 🛏️ Inpatient Admissions: Scheduled hospital stays and acute rehab
  • 🔪 Surgeries: Major elective or specialized procedures
  • 👃 Cosmetic/Reconstructive: Procedures like rhinoplasty or blepharoplasty

🦽 Equipment & Specialized Care

  • 🦼 Durable Medical Equipment: Wheelchairs, hospital beds, and oxygen
  • 🧬 Medical Oncology: Chemotherapy and specialized cancer treatments
  • 🏃 Therapy Services: Extended physical, occupational, or speech therapy

What services typically require prior authorizations?

Health insurance plans typically require prior authorization for expensive, complex, or non-emergency medical services, tests, and specialty drugs before they agree to pay.

Common Services Requiring Prior Authorization

  • Advanced Imaging: High-tech scans like MRIs, CT scans, and PET scans.
  • Surgeries and Procedures: Elective inpatient and outpatient surgeries, bariatric procedures, and planned hospital admissions.
  • Specialty and High-Cost Medications: Brand-name drugs, specialty pharmaceuticals, and prescriptions exceeding specific cost thresholds.
  • Durable Medical Equipment (DME): Costly items like motorized wheelchairs, hospital beds, and expensive prosthetics or orthotics.
  • Therapies: Physical therapy, occupational therapy, speech therapy, and applied behavior analysis (ABA).
  • Specialized Care and Testing: Genetic testing, organ transplants, home health nurse visits, and out-of-network specialist referrals.

Note: Emergency medical care is exempt and never requires prior authorization. You can review specific plan rules through your insurer's UnitedHealthcare Plan Guidance or by reading your policy's Harvard Health Overview.

Can a doctor refuse to do a prior authorization?

Yes, a doctor can technically refuse or delay doing a prior authorization, though it goes against standard medical practice and their contractual obligations to insurance networks.

Why a Doctor Might Refuse or Delay

  • Administrative Burden: Clinics spend many hours each week on paperwork, phone calls, and faxes for prior authorizations, pulling staff away from patient care.
  • Philosophical Stance: A small number of independent or "insurance-free" doctors completely refuse to participate in prior authorization systems on principle.
  • Not Medically Indicated: If a doctor no longer believes a test or medication is appropriate or safe for your condition, they will not submit paperwork to justify it.

What Happens If They Refuse

  • OutOf-Pocket Costs: If your doctor refuses to submit a required prior authorization, your insurance company will not cover the service or drug. You would have to pay the full cost yourself.
  • Care Delays: Refusals or slow-walked paperwork stall necessary medical treatments.

What You Can Do

  • Switch Providers: You can ask another in-network provider to take over your care and submit the required paperwork.
  • Contact Patient Relations: If you belong to a large medical group or hospital network, file a complaint with their patient advocacy department.
  • Call Your Insurance: Explain that your provider is unresponsive or refusing to submit the request; sometimes the insurer can intervene or guide you on alternative steps.

What procedures require prior authorization?

Prior authorization is an approval from a health insurance company required before they cover specific non-emergency medical services, surgeries, or medications.

Common Procedures Requiring Prior Authorization

Insurance plans and Medicare Advantage generally require prior approval for high-cost, specialized, or elective treatments. Typical categories include:

  • Planned Surgeries: Non-emergency inpatient and outpatient procedures (such as joint replacements or spinal surgeries).
  • Advanced Imaging: High-cost diagnostic tests like MRIs, CT scans, and PET scans.
  • Nerve and Spinal Treatments: Procedures like electrical nerve stimulators, deep brain stimulation, and cervical fusions.
  • Specialized Therapies: Radiation therapy, genetic testing, and specialized or high-risk drugs.
  • Durable Medical Equipment: Heavy medical devices, motorized wheelchairs, or ongoing home oxygen equipment.
  • Cosmetic/Reconstructive Procedures: Surgeries that can be cosmetic or medically necessary, such as blepharoplasty (eyelid surgery), vein ablation, or panniculectomy (skin removal).

For specific official guidelines on government-regulated outpatient rules, check the CMS Prior Authorization List.

How to know if a procedure requires prior authorization?

To know if a medical procedure requires prior authorization, you must check directly with your health insurance plan or ask your healthcare provider before getting the care.

Steps to Find Out

  • Call your insurance company: Look at the phone number on the back of your insurance card and ask member services if your specific procedure needs prior approval.
  • Get specific codes: Ask your doctor for the CPT code (current procedural terminology for the procedure) and the ICD-10 code (diagnosis code) so your insurer can give you an exact answer.
  • Check your online member portal: Log into your health plan’s website or app to look at your plan's coverage rules, benefit booklet, or pre-authorization lookup tools.
  • Ask your doctor's office: Healthcare providers check insurance rules daily and usually know if a planned surgery, scan, or treatment requires approval.

Common Services That Need Prior Authorization

  • Planned or non-emergency surgeries
  • High-level imaging like MRIs and CT scans
  • Non-emergency hospital stays
  • Specialized medical equipment

Most users on Reddit agree that getting the exact billing and diagnosis codes from your doctor first is the best way to get a clear answer from your insurance company.

Understanding Prior Authorization

9 related questions found

What are three drugs that require prior authorization?

Many health insurance plans require prior authorization (pre-approval from the insurance company before they will cover the cost) for specialty, high-cost, or controlled medications. Three common examples of drugs that frequently require prior authorization include:

  • Ozempic (semaglutide): Often prescribed for type 2 diabetes, insurers frequently require prior authorization to ensure it is being used for an approved medical condition rather than off-label cosmetic weight loss, or to verify that step therapy requirements (trying preferred alternatives first) have been met.
  • Botox (onabotulinumtoxinA): While widely known for cosmetic use, therapeutic applications like chronic migraine prevention, severe muscle spasticity, or bladder dysfunction routinely require prior authorization from insurance to confirm medical necessity.
  • Humira (adalimumab): As an expensive biologic medication used for chronic inflammatory conditions like rheumatoid arthritis or Crohn's disease, plans require prior authorization to verify diagnosis criteria and ensure patients have tried standard first-line treatments (such as traditional nonsteroidal anti-inflammatory drugs or methotrexate) without success.

What's the difference between precertification and prior authorization?

While many health insurance companies use precertification and prior authorization interchangeably, some medical billing offices draw a subtle operational distinction between the two based on the type of care.

Key Differences

  • Interchangeable Usage: The American Medical Association (AMA) and most major health plans treat both terms as the exact same advance-approval process required before a service is delivered.
  • Precertification Focus: When separated operationally, precertification usually verifies that a planned service, facility stay, or inpatient admission is a covered benefit under the patient's specific health plan.
  • Prior Authorization Focus: Prior authorization (or preauthorization) typically involves a deeper clinical review to establish the strict medical necessity of a specific outpatient test, specialty drug, or advanced procedure.
  • Type of Service: Precertification is more commonly tied to inpatient hospital admissions, rehab stays, or facility surgeries, whereas prior authorization is frequently required for outpatient imaging (like MRIs), costly specialty medications, and specific treatments.

Why do doctors hate prior authorization?

Doctors dislike prior authorization because it creates heavy administrative work, delays patient care, and undermines their clinical judgment.

Heavy Administrative Burden

  • Wasted time: Doctors and their staff spend roughly 12 to 16 hours every week filling out forms, faxing documents, and waiting on hold.
  • Burnout: Managing dozens of authorization requests per doctor each week contributes significantly to staff fatigue and physician burnout.
  • Frustrating reviews: The "peer-to-peer" appeals often require doctors to justify clear medical decisions to non-physicians or reviewers outside their specific medical specialty.

Harm to Patients

  • Care delays: Over 90% of physicians report that the approval process delays necessary medical treatment or prescription refills.
  • Adverse health events: Surveys by the American Medical Association show that one-third of doctors report prior authorization leading to serious medical outcomes like hospitalizations or permanent disability.
  • Treatment abandonment: Many patients give up and stop trying to get care when facing complicated insurance roadblocks.

Distrust of Insurance Motives

  • Second-guessing expertise: The process requires doctors to get a third-party corporate insurer's permission to practice medicine they already trained years to perform.
  • Cost-cutting focus: Clinicians feel the system is designed primarily to boost insurance company profits by blocking or delaying costly treatments rather than improving health.

What not to say to your doctor?

Avoid telling lies or holding back important facts about your health habits, medications, or lifestyle.

What to Avoid Saying

  • Untruths about habits: Do not claim you quit smoking, stopped drinking, or take your medications when you do not. Your doctor needs the truth to keep you safe.
  • "Just one more thing...": Do not drop a major medical concern at the very end of the visit. It cuts into needed time.
  • Aggressive or rude remarks: Do not use loud, hostile, or sarcastic language. Treat your doctor as a partner.
  • Demands for special favors: Do not ask a doctor to break insurance rules, falsify work notes, or treat family members without an appointment.
  • Aggressive self-diagnoses: Avoid stating "I read online that I have X" as an absolute fact. Instead, ask the doctor to review your online research together.

What is a common reason for a prior authorization required rejection?

A common reason for a prior authorization rejection is missing or incomplete clinical documentation. Insurance companies often reject requests because they lack required lab results, imaging reports, or clinical notes.

Other Common Reasons

  • Lack of Medical Necessity: The submitted details do not prove the treatment or medication meets the payer's clinical guidelines.
  • Coding Errors: The CPT (procedure) or ICD-10 (diagnosis) codes are wrong or do not match.
  • Step Therapy Requirements Not Met: The patient did not try or fail lower-cost, preferred alternative treatments first.
  • Non-Formulary Drugs: The requested medication is not on the insurance plan's approved drug list.