By the time a patient of Kasra Ahmadinia, MD, finally received approval for spine surgery, nearly six months had passed.
First came physical therapy. Then injections. Then additional waiting periods between injections. When the patient returned for approval again, the insurer responded with a new requirement: the earlier physical therapy was now considered outdated and had to be repeated.
“The goalposts are moved all the time,” Dr. Ahmadinia said.
For the patient, the process meant months of continued pain. For Dr. Ahmadinia, a spine surgeon at Tulsa-based Advanced Orthopedics of Oklahoma, it reflected what he sees as a growing problem in modern healthcare: medical decisions increasingly shaped not by physicians, but by rigid administrative systems and, increasingly, algorithms.
When delays become the treatment
Prior authorization was originally designed as a safeguard, a way for insurers to limit unnecessary procedures and control healthcare spending.
But many spine surgeons argue the process has expanded far beyond that role.
According to Dr. Ahmadinia, patients with clear surgical pathology are often required to complete lengthy sequences of therapy, injections and repeat evaluations before surgery can move forward, even when both physician and patient believe the outcome is unlikely to change.
“We’ve had patients get the runaround and eventually just cancel surgery altogether,” he said.
In spine care, he said, the issue is particularly common with lumbar fusion procedures, where insurers frequently require weeks of documented physical therapy before approving surgery.
Dr. Ahmadinia refers to it as the “PT trap.”
For some patients, he said, the requirement feels disconnected from reality.
“They can barely walk,” he said. “And you’re telling them they need to exercise for six weeks.”
Eventually, many of those patients undergo surgery anyway, only after months of additional appointments and failed conservative treatments.
The delays become more concerning, he said, when neurologic symptoms are involved.
“When you have weakness, the longer we wait, the harder it is to get some of that back,” he said.
The frustration of the ‘peer-to-peer’ process
For physicians, some of the most frustrating interactions occur during peer-to-peer reviews, conversations between surgeons and insurance representatives after a procedure has been denied.
In theory, the process allows doctors to explain why a patient falls outside standard criteria. In practice, Dr. Ahmadinia said, the conversations often feel scripted.
“You can say all you want to say, no matter what’s going on,” he said. “They’ll just say, ‘You haven’t done this.’”
At times, he added, the reviewing physician is not even a spine specialist. “I want it to be a spine surgeon that I’m talking to,” he said.
To him, the process increasingly resembles a checklist exercise, one where nuance matters less than whether a required box has been marked.
The rise of AI-driven denials
Now, Dr. Ahmadinia believes another layer is reshaping the process: AI.
According to him, some insurers are increasingly relying on AI systems to scan charts, identify missing criteria and issue denials before a human reviewer becomes involved. “The insurance company will have an AI look through the patient’s chart,” he said. The concern is not simply that AI is being used, but that it may reduce complex clinical decisions into keyword recognition and documentation patterns.
For physicians, that changes how medicine is practiced. “We’re going to start using AI to make sure we say the right things to get through their AI systems,” he said.
The result, he fears, is a system where physicians spend increasing amounts of time documenting for algorithms rather than caring for patients.
“It just becomes a game,” he said.
A different model: ‘Gold carding’
Dr. Ahmadinia believes there may be a more targeted way to approach prior authorization.
He pointed to “gold carding” programs, including one implemented in Texas, where physicians with consistently high approval rates are temporarily exempted from certain authorization requirements. The idea is to reduce administrative burdens for physicians who consistently follow evidence-based care pathways and routinely receive approval anyway.
“If 90% of these cases are being approved anyway, focus the oversight on the people who may not be following the appropriate standards,” he said.
Supporters say the model could speed access to care and allow insurers to focus oversight on outlier cases instead. But implementation has been uneven. According to the Texas Medical Association, only a small percentage of physicians have ultimately qualified for exemptions so far.
Still, Dr. Ahmadinia sees the concept as a way to reward physicians with strong outcomes and consistent clinical decision-making. “Most doctors, I would imagine, are pretty ethical,” he said.
Who ultimately controls care
At the center of the debate, according to Dr. Ahmadinia, is a larger question about authority in medicine.
Physicians are already monitored through licensing boards, peer review and outcomes data, he said. Surgeons who consistently perform unnecessary procedures rarely maintain successful practices for long.
“The doctors that have been around for 15, 20, 30 years are having good results,” he said. What troubles him most is the growing distance between those making authorization decisions and the patients affected by them.
“We self-police,” he said. “Why do we need this other entity that has nothing to do with the day-to-day life of these patients telling them what they can and can’t have?”
As prior authorization systems become increasingly automated, that tension may only intensify, raising a broader question for healthcare: whether clinical decision-making will continue to rest primarily with physicians, or increasingly with the systems designed to oversee them.
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