When Insurance Gets in the Way of Your Care

There is a conversation I have had too many times in my office. A patient has been waiting weeks for a procedure. Their pain is real. The clinical indication is clear. The plan is straightforward. And then — a denial letter arrives, not because the treatment is inappropriate, but because of a documentation technicality that has nothing to do with whether the procedure will help them.

I want to talk about this honestly, because I think patients deserve to understand what is happening behind the scenes — and why their care is sometimes delayed in ways that have nothing to do with their doctor, their diagnosis, or their need.

The Prior Authorization System

Before many procedures can be performed, insurance companies require something called prior authorization — a formal review process in which the insurer evaluates whether they consider the requested treatment medically necessary. In principle, this sounds reasonable. In practice, it has become one of the most significant barriers to timely care in modern medicine.

The criteria insurers use to grant or deny authorization are not fixed. They change. Sometimes annually, sometimes more often. What qualified for approval last year may not qualify this year — not because the science changed, not because the procedure became less effective, but because the policy was updated. Providers are expected to keep pace with these changes across dozens of different insurance plans, each with their own requirements, their own forms, and their own timelines.

A Recent Example That Illustrates the Problem

I recently had an authorization request denied for a sacroiliac joint injection — a well-established, minimally invasive procedure used to treat lower back and hip pain originating from the SI joint. The denial was not based on a question about whether the patient needed the procedure. It was not based on a missing diagnosis or inadequate clinical documentation.

The denial came because I had not explicitly stated that the volume of injectate would be less than 2 mL. That was it. The insurer required that specific threshold to be documented in the prior authorization request — and because it was not written out, the authorization was refused.

Every pain physician knows that the joint has limited capacity. A sacroiliac joint injection requires a small volume — that is not a preference or a style choice, it is basic anatomy. Injecting an excessive volume would be clinically inappropriate and counterproductive. This is not a nuance — it is foundational procedural knowledge. The insurer is not teaching us anything by requiring it to be stated. They are simply creating a condition for denial.

What makes this particularly difficult to accept is the selective nature of the requirement. Volume documentation of this kind is not routinely required for other spinal injections I perform. Epidural steroid injections, medial branch blocks, facet injections — for these, I am not instructed to specify injectate volume in the prior authorization. And so, naturally, I do not. Why would I? There is no stated requirement.

But for the sacroiliac joint injection specifically, this criterion exists. No explanation is given for why this particular procedure has been singled out. No clinical rationale is offered. The criteria simply list it as a requirement, and if it is absent, the authorization is denied.

When requirements are applied inconsistently across similar procedures, and when those requirements carry no clinical reasoning behind them, it is reasonable to ask what purpose they serve. The effect, whatever the intent, is that the patient waits. The appeal process begins. Time passes. And throughout that time, they continue to experience pain that the procedure was designed to address.

This is what is meant when physicians say that insurers are now guiding care at an intimate level. It is not merely that they approve or deny a treatment in broad strokes. They are now inserting themselves into the procedural specifics — volumes, dosages, techniques — not as clinicians, but as policy writers. And unlike a clinician, they are not in the room. They will never be in the room. But their criteria are there with us every time we treat a patient.

Shifting Criteria and the Burden on Patients

One of the most frustrating aspects of this system — for both patients and providers — is how frequently the criteria change. Requirements that did not exist two years ago are now standard. Documentation thresholds have become more specific, more granular, and in some cases, more disconnected from clinical reality.

Patients often do not know about these changes until they are affected by them. Sometimes a denial letter reaches a patient before their physician has even been notified. Sometimes it is the other way around — the office receives a denial and has to call the patient to explain a delay they did not expect. Either way, the experience is disorienting and, understandably, distressing.

When someone is in pain — real, daily, life-limiting pain — being told that their treatment has been delayed over administrative criteria is not an abstraction. It is another week of disrupted sleep, another week of avoiding activities they love, another week of managing symptoms that should already be treated.

What This Looks Like From the Clinical Side

As a physician, navigating this system is a constant recalibration. Every time criteria update, we update our documentation templates, our intake processes, our prior authorization workflows. We assign staff specifically to manage authorizations. We build in buffer time for appeals. We anticipate denials on certain procedures with certain insurers because we have seen the patterns.

None of that time or effort goes toward patient care. It goes toward satisfying a parallel administrative system whose requirements are set not by clinical evidence, but by policy.

I do not say this with bitterness. The people reviewing these requests are doing their jobs within a system that was designed with certain goals in mind. But the aggregate effect of that system on patients — particularly those with chronic pain, who may be dealing with multiple insurers, multiple procedures, and multiple appeals simultaneously — is something that warrants honest examination.

Why It Seems to Be Getting Worse

The trend toward more granular, more frequently updated prior authorization requirements is not accidental. Administrative delays have a financial effect: they defer the expenditure of claims dollars, and in some cases, patients who experience enough friction in the authorization process discontinue their pursuit of care entirely. Whether or not that is the intent, it is the outcome — and it is measurable.

Several major medical associations, including the American Medical Association, have documented the extent to which prior authorization burdens have increased over the past decade. The data shows that the volume of authorization requirements, the frequency of denials, and the time physicians spend on administrative tasks related to authorizations have all increased substantially. This is not a perception — it is documented and ongoing.

What Needs to Change

There are reasonable, workable reforms that have been proposed and in some cases legislated — though implementation remains uneven. Gold carding, for example, allows physicians with strong authorization approval records to bypass the prior authorization process for certain procedures. Several states have adopted versions of this. Standardization of authorization criteria across plans — rather than allowing each insurer to define their own requirements independently — would reduce the cognitive and administrative burden on practices significantly.

Real-time authorization systems, which some insurers are beginning to explore, could reduce delays from weeks to hours for straightforward cases. And greater transparency about how criteria are set and updated would at minimum allow providers to prepare more effectively.

These are not radical ideas. They are incremental steps toward a system that keeps the patient — not the paperwork — at the center of the process.

A Note to My Patients

If you have experienced a delay in your care due to prior authorization — whether for an injection, a medication, a referral, or any other service — I want you to know that your frustration is valid. It is not a reflection of your physician not advocating for you. In most cases, your provider is working through a system that was not designed with your timeline in mind.

If you receive a denial letter, contact your provider's office. Do not assume the decision is final. Many denials are successfully appealed, particularly when additional clinical documentation is submitted. The process is tedious, but it works more often than people realize.

And if you want to make your voice heard on this issue beyond the individual claim level, contact your state legislators. Prior authorization reform is an area where patient advocacy genuinely moves the needle. Organizations like the Patient Access Network Foundation and state medical associations are actively working on these issues and welcome public support.

Looking Forward

I remain optimistic — not naively, but because I have seen the system respond to sustained pressure over time. The conversation around prior authorization reform is louder now than it has ever been. Physicians, patients, and patient advocacy organizations are aligned on this in a way that is unusual in healthcare policy. That alignment matters.

The goal is not to eliminate accountability in healthcare spending. The goal is to ensure that the administrative layer of that accountability does not become a barrier to care for the people who need it most. We are not there yet. But the direction is right, and the momentum is building.

In the meantime, my commitment to every patient I see is the same: I will advocate for the treatment you need, work through whatever process is required to get you there, and be transparent with you when the system creates delays that are outside of my control. You deserve nothing less.