Prior authorization (PA) is a utilization management process in which a health plan reviews and approves a procedure, treatment, or medication before it is provided.
The PA process verifies coverage before services are provided, helping reduce claim denials. Additionally, PA verifies the medical necessity of services and controls costs. However, in oncology, prior authorization challenges are one of the biggest reasons for disruptions in cancer care delivery.
Regimens change quickly based on how a tumor responds, and every adjustment can lead to the need for a fresh authorization request.
According to the American Medical Association (AMA), 95% of physicians believe that prior authorization can lead to delays in necessary care. Additionally, 79% report that patients are forced to abandon treatment due to authorization holdups.
In 2022, the American Society of Clinical Oncology (ASCO) also found that nearly all surveyed oncology providers reported delayed care and other patient harms due to prior authorization challenges.
These findings underscore the importance of understanding prior authorization challenges in oncology practices and their impact on patient care and reimbursement.
Prior Authorization Delays Faced by Oncology Practices
Prior authorization challenges in oncology arise from multiple factors. However, the complexity of cancer care itself remains the biggest challenge. Cancer treatment is far more complex than routine prescription renewals or many other healthcare services.
An oncology prior authorization requires detailed clinical documentation. This may include:
- Staging information
- Pathology reports
- Prior treatment history
- Biomarker or genomic testing results
- A rationale tied to National Comprehensive Cancer Network guidelines.
Therefore, gathering the documentation requires time and effort that the clinical staff may not always have. Prior authorization requests generally cannot be submitted until this documentation is complete.
Beyond documentation requirements, several other factors contribute to prior authorization delays. The following are the other factors:
Peer-to-Peer Review Requirements
Pre-authorization requests for oncology treatments are among the most heavily scrutinized. Sometimes, when an authorization is requested, it might get flagged. When this occurs, physicians may be pulled away from direct patient care.
Instead, they must first provide a comprehensive justification for the treatment decisions. The justification is typically discussed with a payer’s medical reviewer, which can take weeks to schedule the call.
High Cost of Therapies
According to the American Cancer Society (ACS) and the University of Texas MD Anderson Cancer Center, the rising costs of cancer treatments have led to increases in total costs of care.
These rising costs may impact infused and oral anticancer drugs, costing tens of thousands of dollars each month. As a result, payers often require extensive documentation to establish medical necessity before approving coverage.
Frequent Regimen Changes
Cancers can respond differently in each case, requiring regimen changes. Oncologists may:
- Adjust dosage
- Switch agents
- Add supportive therapies
Each time an oncologist makes a regimen change, it requires prior authorization before it can be implemented. This authorization may not be approved immediately, which can also slow down the clinical intervention.
Understaffed Authorization Teams
Oncology is one of the most burdened medical specialties in the country. Many oncology treatments require extensive prior authorization request submission, consuming endless hours of administrative time.
Generally, oncology practices are understaffed and lack sufficient resources to allocate for PA requests. As a result, administrative work often takes time away from direct patient care.
Oncology Prior Authorization Changes
According to the American Cancer Society, in 2026, there will be an estimated 2,114,850 new cancer cases and 626,140 deaths in the U.S.
From a billing perspective, this patient growth will increase the volume of authorization requests and the administrative burden on oncology practices. The result? Additional prior authorization challenges.
Fortunately, certain oncology PA changes are being implemented to counter these rising challenges. These include:
Awareness of Prior Authorization Challenges
Growing awareness of authorization challenges in oncology has prompted reform efforts among regulators, lawmakers, and health insurers. Unfortunately, the implementation of these reforms has been a serious challenge, according to the AMA.
In 2025, almost 60 health insurers pledged to streamline authorization processes, which included:
- Reducing the number of services requiring prior authorization.
- Ensuring medical necessity denial review is done by a licensed clinician.
Unfortunately, the follow-up survey showed disappointing results. Only 33% of physicians believe the pledges have had a meaningful impact on day-to-day practice.
Changes on the Policy Side
On the policy side, the ASCO continues to advocate for structural reforms to the pre-authorization process. The organization is openly supporting the proposed federal rule changes.
If finalized, electronic prior authorization application programming interfaces (APIs) would be required for prescription drugs. Additionally, each authorization request will operate under a defined decision window.
The proposal establishes response timeframes of 24 hours for expedited requests and 72 hours for standard requests.
The organization has also requested a stronger review of artificial intelligence tools used to process and deny PA requests. They warn that automated denials without clinician review may lead to an increase in prior authorization challenges in oncology practices rather than solve them.
The Key Takeaway for Billers: Changes in prior authorization policies will lead to new payer-specific billing and documentation requirements, making ongoing monitoring essential.
Oncology Procedures with Complex Authorization Processes
Not all oncology services carry the same prior authorization challenges. Several categories of oncology services present greater PA challenges than others. The following are some examples of these categories and how PA challenges impact each one:
Radiation Therapy Planning
Radiation therapy planning involves advanced imaging and techniques such as IMRT, SBRT, or proton therapy. The extensive documentation required for these advanced techniques can prolong the prior authorization process and delay the start of radiation therapy.
Oral Oncolytics
Oral oncolytics are prescription cancer medications taken by mouth. These medications are typically dispensed via specialty pharmacies.
Since these medications are typically covered under the pharmacy benefit, and not the medical benefit, a separate PA workflow may be required.
This additional coordination between providers, pharmacies, and insurers increases administrative burden and can delay treatment initiation.
Anti-VEGF Therapies
Anti-vascular endothelial growth factor (anti-VEGF) therapies inhibit the formation of new blood vessels that tumors require for growth. Payers often require documentation of medical necessity or evidence of step therapy before approving anti-VEGF treatment.
Due to this requirement, the PA review process can be delayed, potentially delaying treatment initiation.
Immunotherapies
Immunotherapies activate the immune system to fight cancer. Because they are high-cost and indication-specific, they often require detailed documentation and PA, delaying treatment.
Genomic/Biomarker Testing
Genomic and biomarker testing identify molecular markers that guide the selection of targeted cancer therapies.
Many payers require prior authorization for genomic or biomarker testing, and the targeted therapy selected based on those results may require a separate authorization.
These sequential prior authorization requests create administrative delays before treatment begins.
Supportive Care Drugs
Supportive care drugs include antiemetics, growth factors, and bone-modifying agents. They help manage side effects of treatment. Separate PAs may delay supportive care and affect treatment adherence.
CAR T-Cell Therapy
CAR T-cell therapy involves genetically modified T cells to target cancer. Its complexity and high cost require extensive prior authorization and medical review by the payer, leading to treatment delays.
Common Reasons for Oncology Prior Authorization Denials
Even well-documented authorization requests for oncology services may be denied due to underlying triggers that often go unnoticed. These reasons commonly include:
- Some insurers only cover certain treatments when administered in approved care settings. These settings may include home infusion rather than a hospital outpatient facility.
- Prior authorizations often have expiration dates. Treatments beyond these approved periods may require a renewed approval.
- Mismatched diagnosis and procedure or medication codes lead to automatic denial before clinical review.
- Insurers may require patients to try and fail a lower-cost treatment before approving the requested therapy, even when the oncologist recommends skipping that step.
- Initial submissions may be delayed or denied if key clinical records are missing. These records may include cancer staging, previous treatment history, and pathology reports.
- Coverage may be denied if the patient’s case does not meet the insurer’s medical necessity requirements, which may differ from those outlined by NCCN or the FDA.
How Streamlined Prior Authorization Helps Oncology Practices
Prior authorization challenges in oncology practices are a part and parcel of patient care and medical billing. However, the regulatory pressure is driving the need for a faster and more transparent PA process.
Practices wishing to counter prior authorization challenges in oncology must optimize their internal processes. Unfortunately, practices with high patient volume may be short-staffed to handle these tasks efficiently.
The oncology billing services at MediBillMD provide the necessary assistance against authorization challenges.
