Researcher found 80% of claim denials were ultimately reversed, reinforcing long-standing concerns raised by AAOS and patient advocates
NEW ORLEANS, March 2, 2026 /PRNewswire/ — As public and private health plans seek to reduce rising medical costs, requiring prior authorization (PA) for high-cost procedures has become standard. A new study presented at the 2026 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) found that patients with degenerative spine disease had their surgery delayed, resulting in prolonged pain and no cost savings benefit to the payer.
Currently, 99% of patients in the United States 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 reports. When care is denied, patients may pay out of pocket for procedures, forcing some into medical debt, which accounts for 66% of all personal bankruptcy filings in the U.S., according to the Scheinman Institute at Cornell University.
“As the U.S. health care 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, MD, MBA, orthopaedic 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,” Dr. Turk explained. “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, along with the principal investigator, Brad Segebarth, MD, 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 orthopaedic spine surgeons at a private orthopaedic 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 due to 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 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 15.7 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 PA is likely to delay care and increase costs for patients, physicians and the overall health care system.”
As the population ages, the need for surgical treatment of 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 regulations on workplace safety could further fuel this trend, Turk noted.
AAOS Efforts on Prior Authorization
The American Association of Orthopaedic Surgeons 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. Learn more at the AAOS Advocacy Action Center at aaos.org/advocacy.
2026 AAOS Annual Meeting Disclosure Statement
About AAOS
With more than 39,000 members, the American Academy of Orthopaedic Surgeons is the world’s largest medical association of musculoskeletal specialists. AAOS is the trusted leader in advancing musculoskeletal health. It provides the highest quality, most comprehensive education to help orthopaedic surgeons and allied health professionals at every career level to 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.
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SOURCE American Academy of Orthopaedic Surgeons
