Category: Spine Surgery | Author: Stefano Sinicropi | Date: March 24, 2026
If you’re considering an elective spinal procedure, you’ll likely need to get prior authorization from your health insurance provider before you can move forward with the procedure with the knowledge that your claim will be approved by your insurer. Oftentimes prior authorization is granted because the physician overseeing your care can make a compelling case as to why the procedure is medically necessary, but you also play a role in whether or not you earn this prior authorization.
But what could cause your health insurer to deny your claim, and what can you do to avoid prior authorization denial? In today’s blog, we look at some of the reasons why your health insurer may deny your request for prior authorization ahead of your elective spine surgery.
Why Prior Authorization Is Denied For Spine Surgery?
A recent study took a closer look at the impact prior authorization denial had on patients, and in the study researchers uncovered some of the most common reasons why prior authorization was not granted. Some of those reasons for prior authorization denial include:
- Lack Of Conservative Care Efforts – When it comes to the management of an issue that can be treated with an elective procedure, your doctor and your insurance company will likely want to avoid the more invasive care routines if possible. In many instances, conservative treatment recommendations will be made to see how the spine responds to this type of care before authorization for surgery is granted. In the study, roughly 1 in 3 patients whose prior authorization for surgery was denied was the result of not pursuing at least six weeks of physical therapy before considering surgery.
- Not Medically Necessary – Perhaps the most frustrating denial comes when the insurer says that the procedure is not medically necessary. If your physician believes that it is medically necessary, but an insurance agent who sits behind a desk feels like other routes should be pursued first, it can be quite an exasperating experience. In the study, more than 1 in 4 patients whose claims were denied were told that surgery was not medically necessary.
- No Proof Of Quitting Smoking – If the insurance company is going to cover your elective spine surgery, they want you to meet them half way. If a patient isn’t going to quit smoking, the insurer may feel like paying for surgery may be a waste, since smoking complicates the procedure and the recovery likelihood. In the study, 15% of patients whose prior authorization was denied were told the denial was the result of the absence of proof that they had tried to quit smoking.
- Incomplete Information – Finally, another reason why prior authorization may be denied is because documentation related to the request is missing or incomplete. This is probably the “best” reason for denial, but it is still time consuming to fix these issues, and that can lead to more pain or a worsening condition. Some claims are denied until the insurance company receives more information, which is why it’s important to connect with a care facility who knows how to file for prior authorization and advocate on the behalf of their patients.
We can help you navigate a denial or work to achieve prior authorization for spine surgery on the first request. For more information on how we’ll work to do this, or to connect with a spine specialist about a different issue, reach out to Dr. Sinicropi and the team at Midwest Spine & Brain Institute today at (651) 430-3800.
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