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Although public and private health plans typically require prior authorization for high-cost medical procedures, a new study presented at the 2026 Annual Meeting of the American Academy of Orthopaedic Surgeons indicates that prior authorization does not reduce rising medical costs, at least for patients with degenerative spine disease.

The study authors found that when surgery for patients with degenerative spine disease was delayed due to prior authorization requirements, the result was prolonged pain, and no cost savings benefit for the payer.

Alignment with Value-Based Care?

Currently, 99% of patients in the US who are covered by public, private, or employer-sponsored health plans are subject to prior authorization rules for high-cost procedures such as surgery, imaging, and specialty drugs, according to the Kaiser Family Foundation.

When care is denied, patients may pay out of pocket for procedures, forcing some into medical debt, which data from the Scheinman Institute at Cornell University show accounts for 66% of all personal bankruptcy filings in the US.

“As the US healthcare system transitions to value-based care aimed at reducing costs while maintaining or improving outcomes, current practices such as prior authorization require continued evaluation,” said Rob Turk, MD, MBA, orthopaedic surgery resident at Carolinas Medical Center in Charlotte, North Carolina.

“With this study, we wanted to understand whether prior authorization actually aligns with the principles of value-based care,” Dr. Turk said. “Specifically, we looked for patterns in denials of recommended spine procedures to determine if the process supports evidence-based care or creates barriers.”

Key Findings of the Study

Dr. Turk and colleagues retrospectively reviewed the charts of more than 7000 US adults recommended for elective surgeries by board-certified orthopaedic spine surgeons at a private orthopaedic practice.

The study included cases from January 2021 to December 2024 and focused on patients with degenerative spine disease in the lumbar and cervical spine regions. During this period, insurers denied coverage for 460 patients (nearly 7% of all patients studied).

The study authors found that:

• 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 due to a lack of documentation of 6 weeks of physical therapy.
• In 122 cases (26.5%), the insurer deemed elective spine surgery not medically necessary.
• An additional 69 denials (15%) were handed down 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.
• In the end, 374 patients whose care was denied (81.3%) went on to have the recommended surgery, but only after an average delay of 7 days, with a standard deviation of 33 days.

“Patients had to live with the pain that restricted their work, family, and community activities,” said Dr. Turk. “Health plans continued to pay for ineffective care instead of approving procedures that could have helped much sooner.

“Additionally, our findings suggest that prior authorization is likely to delay care and increase costs for patients, physicians, and the overall health care system.”

Source

Turk R, Sullivan BL, Chandler C, Lifsey CS, Moorer WW, Gachigi KK, Segebarth PB. Preauthorization Requirements Delay Care Without Benefit for Elective Spine Surgery. Presented at the Annual Meeting of the American Academy of Orthopaedic Surgeons, March 2-6, 2026, New Orleans, Louisiana.