Prior authorization (PA) for high-cost surgical procedures has become a standard practice as public and private health insurers attempt to reduce rising medical expenses. However, a new study presented at the American Academy of Orthopaedic Surgeons (AAOS) 2026 Annual Meeting found that PA delayed surgery for patients with degenerative spine disease, prolonging their pain and providing no cost savings to the payer.

Currently, 99% of U.S. patients covered by public, private, or employer-sponsored health plans are subject to PA rules for high-cost procedures such as surgery, imaging, and specialty drugs, the Kaiser Family Foundation reported. When care is denied, patients may cover the cost of procedures on their own, forcing some into medical debt, and that debt accounts for 66% of all personal U.S. bankruptcy filings, according to the Scheinman Institute at Cornell University.

“As the U.S. healthcare system transitions to value-based care aimed at reducing costs while maintaining or improving outcomes, current practices such as PA require continued evaluation,” said Rob Turk, M.D., an orthopedic surgery resident at Carolinas Medical Center in Charlotte, N.C. “With this study, we wanted to understand whether PA actually aligns with the principles of value-based care. Specifically, we looked for patterns in denials of recommended spine procedures to determine if the process supports evidence-based care or creates barriers.”

Dr. Turk, principal investigator Brad Segebarth, M.D., and the OrthoCarolina Research Institute team retrospectively reviewed the charts of more than 7,000 U.S. adults recommended for elective surgeries by board-certified orthopedic spine surgeons at a private orthopedic practice. The study examined cases from January 2021 to December 2024 and focused on patients with degenerative spine disease in the lower back (lumbar) region or neck and upper back (cervical) region. During this period, insurers denied coverage for 460 patients (nearly 7% of all patients studied).

Key findings include: 

• Most denials were for stand-alone lumbar decompression (15.4%) and lumbar decompression with instrumented fusion (27.8%).
• In 138 of 460 cases (30%), coverage was denied over a lack of documentation of six weeks of physical therapy.
• In 122 cases (26.5%), the insurer deemed elective spine surgery not medically necessary.
• An additional 69 denials (15%) were rendered because there was no proof that patients who smoked had tried to quit.
• Among the initial denials, 142 (30.9%) required a time-consuming peer-to-peer (P2P) appeal.
• Ultimately, 374 patients whose care was denied (81.3%) eventually underwent the recommended surgery, but only after a 15.7-day average delay, with a standard deviation of 33 days.

“Patients had to live with the pain that restricted their work, family and community activities,” Dr. Turk stated. “Health plans continued to pay for ineffective care instead of approving procedures that could have helped much sooner. Additionally, our findings suggest that PA is likely to delay care and increase costs for patients, physicians, and the overall health care system.”

As the population ages, the need to surgically treat spinal disease is expected to rise dramatically, Dr. Turk noted. Workplace injuries from accidents or repeated motions may increase as employers use digital systems to monitor productivity in factory, warehouse, and logistics operations. Relaxation of federal workplace safety regulations could further fuel this trend, Dr. Turk added.

AAOS has advocated for policy changes to reduce unnecessary delays in care caused by prior authorization, including efforts to improve transparency and limit excessive administrative requirements. The organization supports legislation to modernize the process and protect patient access to medically necessary treatment. It offers tools for physicians and patients to engage with policymakers.

With more than 39,000 members, AAOS is the world’s largest medical association of musculoskeletal specialists. The organization advances musculoskeletal health by providing comprehensive education to help orthopedic surgeons and allied health professionals best treat patients in their daily practices. AAOS is the source for information on bone and joint conditions, treatments, and related musculoskeletal healthcare issues; and it leads the healthcare discussion on advancing quality.