Initial prior authorization denial is associated with increasingly prolonged approval times in outpatient orthopaedic surgery: a 2017-2022 comparative cohort study

Rachel M. Bougazzoul; Carsten Schmidt; Miguel A. Schmitz

doi:10.18203/issn.2455-4510.IntJResOrthop20263888

Authors

Rachel M. Bougazzoul Elson S. Floyd College of Medicine, Spokane, Washington, USA https://orcid.org/0009-0009-5255-2097
Carsten Schmidt Elson S. Floyd College of Medicine, Spokane, Washington, USA https://orcid.org/0009-0005-9924-8202
Miguel A. Schmitz Elson S. Floyd College of Medicine, Spokane, Washington, USA; Alpine Orthopaedic and Spine, Spokane, Washington, USA https://orcid.org/0000-0002-7350-2605

DOI:

https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20263888

Keywords:

Prior authorization, Care delays healthcare access, Insurance denial, Orthopaedic surgery, Utilization management

Abstract

Background: Prior authorization (PA) is widely used by insurers to manage healthcare costs but may delay care, especially after an initial denial. While physician surveys report rising administrative burden from PA, objective data quantifying how denials affect approval timelines remain limited. This study evaluated whether an initial PA denial was associated with longer approval times for outpatient orthopaedic surgery, and whether this delay in care worsened between 2017 and 2022.

Methods: We conducted a retrospective cohort study of PA processing timelines for outpatient shoulder, elbow, hip, and knee surgeries performed by a single orthopaedic surgeon in 2017 and 2022. Cases were categorized as Denial (initial denial followed by eventual approval) or No Denial (approved without appeal or not requiring PA). Welch's two-sample t-tests with 95% confidence intervals compared approval wait times between groups and years.

Results: A total of 169 surgeries were included (58 in 2017, 111 in 2022). The Denial group had significantly longer approval times than the No Denial group in both 2017 (58.7 vs. 10.4 days; p=0.012) and 2022 (132.2 vs. 11.9 days; p<0.001). Among denied cases, mean approval time rose significantly from 2017 to 2022 (58.7 vs. 132.2 days; p=0.014); non-denied cases showed no change.

Conclusions: Initial PA denial was associated with substantially prolonged approval times for outpatient orthopaedic surgery, and delays more than doubled from 2017 to 2022. These findings suggest the burden of PA appeals may be rising and underscore the need for larger multicenter studies to characterize insurer-related delays.

References

American Medical Association. 2025 AMA prior authorization physician survey. Available at: https://www.ama-assn.org/system/files/prior-authorization-survey.pdf. Accessed August 01, 2026.

Pereira DE, Kamara E, Krueger CA, Courtney PM, Austin MS, Rana A, et al. Prior authorization in total joint arthroplasty: a survey of the American Association of Hip and Knee Surgeons membership. J Arthroplast. 2023;38(7):1203-8.

Desmeules F, Dionne CE, Belzile E, Bourbonnais R, Frémont P. Waiting for total knee replacement surgery: factors associated with pain, stiffness, function and quality of life. BMC Musculoskelet Disord. 2009;10(1):52.

Bond M, Charest-Morin R, Street J, Fisher C, Dea N, Singh S, et al. The influence of wait time on surgical outcomes in elective lumbar degenerative spine conditions: a retrospective multicentre cohort study. Glob Spine J. 2025;15(4):2118-28.

Morris JA, Super J, Huntley D, Ashdown T, Harland W, Anakwe R. Waiting lists for symptomatic joint arthritis are not benign. Bone Jt Open. 2020;1:508-11.

Jarrett CD, Dawes A, Abdelshahed M, Cil A, Denard P, Port J, et al. The impact of prior authorization review on orthopaedic subspecialty care: a prospective multicenter analysis. J Shoulder Elbow Surg. 2024;33(6):e336-e342.

Lizcano JD, Goh GS, Tarabichi S, Krueger CA, Austin MS, Courtney PM. Prior authorization leads to administrative burden and delays in treatment in primary total joint arthroplasty patients. J Arthroplast. 2024;39(9):S65-S70.e2.

Yakkanti RR, Call CM, Hannon CP, Krueger CA, Courtney PM, Rana AJ. Prior authorization in joint arthroplasty surgery: navigating challenges. J Arthroplast. 2025;40(5):1104-8.

Murphy J, Beauchamp N, Sun KJ, Lau BD, Wilson RF, Lobner K, et al. Adverse effects of health plan prior authorization on clinical effectiveness and patient outcomes: a systematic review. Am J Med. 2026;139:24-32.e1.

Abe EA, Lizcano JD, Tarabichi S, Parikh N, Sherman MB, Krueger CA, et al. Prior authorization in primary total hip arthroplasty: delays without financial gains. J Arthroplasty. 2025;41(5):1361-9.

Puig-Junoy J, Moreno-Torres I. Impact of pharmaceutical prior authorisation policies: a systematic review of the literature. Pharmacoeconomics. 2007;25(8):637-48.

Ackman ML, Graham MM, Hui C, Tsuyuki RT. Effect of a prior authorization process on antiplatelet therapy and outcomes in patients prescribed clopidogrel following coronary stenting. Can J Cardiol. 2006;22(14):1205-8.

Gotlieb E, Joseph B, Blank L, Jetté N. Barriers and consequences of prior authorization for neurologic medications: a scoping review. JAMA Neurol. 2026;83(2):181-92.

American Academy of Orthopaedic Surgeons. First-of-its-kind study: analysis finds prior authorization delays elective spine surgery without cutting costs. Available at: https://aaos-annualmeeting-presskit.org/2026/research-news/first-of-its-kind-study-analysis-finds-prior-authorization-delays-elective-spine-surgery-without-cutting-costs/. Accessed 01 August, 2026.

Kebaish KJ, Galivanche AR, Mercier MR, Varthi AG, Rubin LE, Grauer JN. Is there utility to requiring spine MRI pre-authorizations? Pre-authorizations: a single institution's perspective. Clin Spine Surg. 2023;36(5):186-9.

Dixon D, Pollard B, Rowley D, Johnson M. Application of the ICF to referral delay in total joint arthroplasty. Qual Saf Health Care. 2010;19(6):e23.

Clement ND, Scott CEH, Murray JRD, Howie CR, Deehan DJ, IMPACT-Restart Collaboration. The number of patients "worse than death" while waiting for a hip or knee arthroplasty has nearly doubled during the COVID-19 pandemic. Bone Joint J. 2021;103(4):672-80.

Hampton M, Riley E, Garneti N, Anderson A, Wembridge K. The orthopaedic waiting list crisis: two sides of the story. Bone Jt Open. 2021;2(7):530-4.

Oussedik S, MacIntyre S, Gray J, McMeekin P, Clement ND, Deehan DJ. Elective orthopaedic cancellations due to the COVID-19 pandemic: where are we now, and where are we heading? Bone Jt Open. 2021;2(2):103-10.

Farrow L, Jenkins PJ, Dunstan E, Murray A, Blyth MJG, Simpson AHRW, et al. Predicted waiting times for orthopaedic surgery: an urgent need to address the deficit in capacity. Bone Joint Res. 2022;11(12):890-2.