Eric Tennant, a 58-year-old father with stage 4 of a rare form of cancer, was a candidate for a relatively new treatment that could potentially shrink a tumor in his liver with ultrasound waves instead of surgery.
Her oncologist recommended the treatment, called histotripsy, but her health insurance company said the potentially life-saving treatment was “not medically necessary,” KFF Health News (1) and NBC News (2) reported.
Tenant’s insurer — West Virginia’s Public Employees Insurance Agency, which partners with UnitedHealthcare — denied four appeals. The treatment would have cost the Tennant family $50,000.
“The insurance company’s decision didn’t just delay care. It closed the door,” his widow, Becky, told KFF Health News (1).
After KFF and NBC contacted the insurer about the denial, the decision was reversed — but it was too late. Tennant’s condition had deteriorated to the point where he was no longer a candidate for treatment. He passed away last September.
But this is not a rare occurrence. This is the result of a process in the health care system called prior authorization, which requires approval by health care professionals before a treatment, service, or drug is eligible for payment.
Almost all Medicare Advantage enrollees (99%) require prior authorization for some services (3).
While the process was designed to limit fraud and control costs, it instead became “a confusing maze that denies or delays care, burdens physicians with paperwork, and perpetuates racial disparities,” according to KFF Health News (4).
The KFF reports that “in recent years it has heard from hundreds of patients who claim that they or someone in their family has been harmed by prior authorization” (5).
A survey by the American Medical Association (AMA) found that nearly 1 in 3 (31%) physicians say prior authorizations are often or always denied. More than 1 in 4 (29%) report that it has “caused a serious adverse event for a patient in their care”, including permanent harm, disability or even death (6).
Most (93%) patients who require prior authorization face care delay, while 82% abandon the recommended course of treatment (6).
In some cases, health insurers can profit by denying high-cost care even as they collect premiums, according to a 2024 U.S. Senate subcommittee investigation. The report points to UnitedHealthcare, Humana and CVS, which each “denied prior authorization requests for post-acute care at a much higher rate than they did for other types of care” between 2019 and 2022 (7).
Read more: Here’s the median income of Americans by age in 2026. Are you falling behind or lagging behind?
There is also concern that insurers using AI to make automated decisions will lead to more prior authorization denials (8).
A voluntary initiative among a group of health insurance companies was announced last year to address these issues, speeding up the review process and making it easier to navigate (9). However, since the initiative is voluntary, it has limitations. And, as a KFF poll shows, few Americans think their insurer will follow through (10).
At the state level, more than 30 states have passed laws in an attempt to better manage prior authorization (11).
According to a KFF survey, half of insured adults (51%) needed to obtain prior authorization before receiving the treatment, service or medication they needed in the previous two years. Among all insured adults, 3 in 10 (29%) say their insurer has delayed or denied their prior authorization claim (10).
The problem is that you may not realize you need prior authorization until you refuse treatment.
To protect yourself from denials, check if prior authorization is required for a treatment, service or drug (the list may change) and make sure all your documents are in order. You can also ask your doctor’s office if they use ePA (Electronic Prior Authorization), which can speed up the review process by fax or phone.
According to an analysis of Medicare Advantage data by KFF (12), more than 8 in 10 denied prior authorization appeals were dismissed between 2019 and 2024. You need to file an appeal within 180 days of the denial, but if your health problem is urgent, you can ask for an external review along with your internal review (13).
But that’s still not guaranteed. For the Tennant family, four appeals were all denied. The insurer took action after the case attracted media attention – and by then it was too late.
If you’re in a similar situation or having trouble navigating the process, you may want to consider seeking help from consumer advocacy groups such as the Patient Advocate Foundation (14). Many states also offer free consumer assistance programs that can help with appeals (15).
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KFF Health News (1), (4), (5); NBC News (2); KFF (3), (10), (12); American Medical Association (6), (8); US Senate Committee on Homeland Security and Governmental Affairs (7); National Health Law Program (9); NPR (11); HealthCare.gov (13); Patient Advocate Foundation (14); Centers for Medicare and Medicaid Services (15)
This article originally appeared on Moneywise.com under the headline: West Virginia father waits for $50,000 cancer treatment his insurer decides is ‘not medically necessary’
This article provides information only and should not be construed as advice. It is provided without warranty of any kind.
