Insurance requirements can be confusing and frustrating. Experts explain why denials happen, how appeals work, and ways to keep care moving, especially for people with neurological conditions.
When Elana Lederman switched health insurance companies last year, her health had a setback. For several years, she had been successfully taking the drugs onabotulinumtoxinA (Botox®) and galcanezumab-gnlm (Emgality®) to prevent chronic migraine headaches. The new insurer required her to go through prior authorization to determine what treatment they would cover.
Also known as precertification or preauthorization, prior authorization requires doctors to get approval from a patient’s health insurance company before a specific service, medication, or procedure is covered.
It can be a frustrating process. Just as in Lederman’s situation, a former health insurer may not have required prior authorization for a treatment, but if you switch plans, the new one may require them. And health insurers can make changes to their requirements each year.
Health insurers say prior authorization is in place to make sure that treatment is medically necessary, safe, and appropriate. But it can also save money for health insurers, especially if patients don’t go through the prior authorization appeal process and choose a less expensive treatment. According to a survey by health research group KFF, nearly half of insured adults say they have had care denied or delayed or had to take medications other than the ones their doctor initially prescribed because of prior authorization requirements. In an article in JAMA Neurology, researchers found that prior authorization can delay care and worsen health conditions for people with neurological diseases such as epilepsy and Parkinson’s disease. The study also found that prior authorization is “particularly concerning in neurology, where timely treatment is critical to avoid disease progression and optimize patient outcomes.”
Health groups, including the American Academy of Neurology, have been advocating for changes to prior authorization for years, with some success and more coming soon. “We’re working toward that at all times,” says Tyler J. Allison, MD, FAAN, program director for the Children’s Mercy Child Neurology residency program in Kansas City. “For the last ten years I’ve been really involved with advocacy in Washington, DC, and at home in Missouri.”
Starting in 2027, certain health insurers and health plans—including insurers offering coverage through the ACA Marketplace, Medicaid, CHIP (Children’s Health Insurance Program), and Medicare Advantage plans—will be required to implement a system that allows electronic submission of prior authorization requests. This is an important change. Paper forms required for fax submissions can slow down the process, as can paper jams, ink, and toner problems.
While that rule doesn’t apply to private insurers who provide employer-based insurance, many major health insurers, including Aetna, Cigna, and the Blue Cross Association, pledged last year to the U.S. Department of Health and Human Services that they would make changes to prior authorization. These changes include standardizing the documentation process and reducing the time required for prior authorization decisions. Major insurers are also removing prior authorization requirements for certain services, such as allowing a 90-day grace period for some previously approved treatments and prescriptions when a patient changes insurers. “These and other proposed changes will ultimately make the process more efficient, which [could get] medicines into the hands of our patients faster,” said Dr. Allison.
Insurers could still delay and deny care, says Rayna Wallace, a policy analyst at KFF who covers prior authorization. “But patients will often know the outcome sooner and if [prior authorization] is delayed or denied, they will be able to start the appeals process sooner.”
Patients say timing is critical. “It took months and many rounds of emails with the doctor and the health insurers to get the authorization for Botox and Emgality,” said Lederman. “And while I waited, the only medications the company would approve were drugs to treat the migraines once they occurred, not the drugs we knew worked for me to prevent them in the first place. It was awful.”
Prior authorization decision appeals can also be done electronically, which could speed up the process and help patients get treatment sooner. Tanina Agosto lives in Brooklyn, NY, and has relapsing-remitting multiple sclerosis. She was on a helpful drug for several years until she developed an allergy to the medication. Each time her doctor wrote a prescription for an alternative drug, the health insurer would say it required prior authorization and first require the drug to which she had an allergy.
“Appeals took a year,” says Agosto. “I was ultimately successful, but I wasn’t on any treatment while I waited,” she says. Rounds of appeals finally allowed Agosto to take the safer drug, after submitting documentation in which she said “[the medication you want me to take] is killing me.”
Sarah M. Benish, MD, FAAN, professor, vice chair of clinical affairs, and the general neurology division director at the University of Minnesota, says the most common reason for denial of a treatment for a neurological condition is that the insurer wants the doctor to prescribe a less expensive or alternate option first. This is known as step therapy.
In September 2025, lawmakers proposed the Safe Step Act to put limits on step therapy. If this bill passes, it could give patients and doctors a clear, quick way to skip step therapy in some cases, so patients can get their medications sooner.
When it comes to medications, doctors and patients often don’t know that prior authorization is required until a patient gets to the pharmacy, says Dr. Benish. “That information isn’t always provided by the insurer at the prescribing point.”
